A nurse is assessing a 35-year-old patient with acute post-streptococcal glomerulonephritis. Which assessment finding would be most indicative of worsening kidney function and require immediate intervention?

Rapid elevation in serum creatinine with severe oliguria indicates acute kidney injury requiring immediate intervention. Other findings are typical of glomerulonephritis but less urgent.

Core Nursing Explanation Key Concept Analysis: This question assesses the nurse's ability to identify signs of acute kidney injury (AKI) in a patient with acute post-streptococcal glomerulonephritis (APSGN). APSGN is an immune-mediated kidney disease where antibodies formed against streptococcal bacteria deposit in the glomeruli, causing inflammation, impaired filtration, and the classic triad of hematuria, hypertension, and edema. The priority nursing action is to monitor for and recognize complications, especially a rapid decline in glomerular filtration rate (GFR), which is life-threatening.

Answer Rationale: Key Point! Option ① is correct because it presents the most objective and severe indicators of deteriorating kidney function. A serum creatinine rise from 1.2 mg/dL (near normal) to 3.8 mg/dL in 24 hours signifies a drastic drop in GFR. This, combined with oliguria (urine output

Nursing Clinical Practice Guide Clinical Scenario: You are caring for Michael, a 35-year-old teacher recently diagnosed with APSGN following a strep throat infection two weeks ago. He was admitted for monitoring. His initial labs showed mild proteinuria and hematuria. On day 2, during your morning assessment, you review his vital signs and lab trends.

Nursing Intervention Strategy:

1. Assessment: Perform a focused assessment. Check vital signs (BP may be elevated). Auscultate heart and lung sounds (crackles may indicate pulmonary edema). Assess for edema (periorbital, pretibial, sacral). Most critically, review the 24-hour I&O sheet and the latest lab results (creatinine, BUN, K+).
2. Nursing Diagnosis: Excess Fluid Volume related to compromised regulatory function (kidney). Risk for Electrolyte Imbalance (hyperkalemia).
3. Planning & Implementation:
   • Immediate Action: Upon discovering the rapid creatinine rise and oliguria (as in option ①), immediately notify the provider (physician/NP). This is a critical change.
   • Fluid & Electrolyte Management: Implement strict I&O. Weigh patient daily at the same time. Restrict fluid and sodium intake as ordered. Monitor for signs of hyperkalemia (muscle weakness, EKG changes like peaked T-waves).
   • Medication Administration: Administer diuretics and antihypertensives as scheduled, monitoring for effectiveness (increased urine output, lowered BP) and side effects (hypokalemia with some diuretics, orthostatic hypotension).
4. Evaluation: Evaluate for stabilization of creatinine/BUN, improvement in urine output, resolution of edema, and control of blood pressure. Monitor for complications.

Patient Safety and Precautions:

• Hyperkalemia Precautions: Hold potassium supplements and potassium-sparing diuretics if hyperkalemic. Be prepared for administration of kayexalate, IV calcium gluconate (cardioprotective), insulin/glucose, or albuterol nebulizers as ordered to lower potassium.
• Medication Caution: Avoid all nephrotoxic medications (e.g., NSAIDs like ibuprofen, certain antibiotics like gentamicin) unless absolutely necessary and closely monitored.
• Infection Control: Practice good hand hygiene. APSGN itself is not contagious, but the preceding streptococcal infection is.

Nursing Procedure & Medication Flow Managing a Patient with Potential AKI: 1. Assessment First: Review I&O, daily weight, labs (creatinine/BUN/K+), lung sounds, and edema. 2. Notify Provider: Report critical findings using SBAR (Situation, Background, Assessment, Recommendation). 3. Implement Orders: May include fluid restriction (e.g., 1500 mL/day), dietary potassium restriction, diuretic administration. 4. Diuretic (Furosemide) Administration: Check BP before giving. Administer IV push slowly (to avoid ototoxicity). Monitor urine output response. Monitor for hypokalemia and ototoxicity (tinnitus, hearing loss). 5. Ongoing Monitoring: Continue strict I&O. Assess for fluid shift: signs of overload (crackles, JVD) vs. dehydration (tachycardia, poor skin turgor).

A Word from Your Senior Nurse "Remember, kidneys are silent workers until they're in trouble. A patient with glomerulonephritis might look okay but have labs screaming that their kidneys are failing. Your vigilance in tracking that I&O and those daily lab values is what catches AKI early. On the NCLEX and in practice, don't get distracted by the dramatic symptoms (like cola-colored urine)—always ask yourself, 'What finding tells me an organ is actually stopping its work?' That's your priority. You are the patient's advocate and early warning system!"