A nurse is caring for a patient with acute kidney injury (AKI) in the oliguric phase. Which nursing intervention should be the highest priority?
1Encourage increased fluid intake to promote kidney function
2Administer diuretics to increase urine output
3Provide a high-protein diet to prevent muscle wasting
4Monitor strict intake and output with fluid restriction✓ 정답
해설
In oliguric AKI, strict intake/output monitoring with fluid restriction is the highest priority to prevent life-threatening fluid overload and complications like pulmonary edema. Other options (increasing fluids, diuretics, high-protein diet) can exacerbate fluid retention or waste accumulation.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a patient in the oliguric phase of Acute Kidney Injury (AKI). The oliguric phase is characterized by a significant decrease in urine output (< 400 mL/day). The primary pathophysiological problem is the kidney's inability to excrete water, electrolytes, and metabolic waste products. This leads to the critical risks of fluid overload, hyperkalemia, and uremia. Therefore, the nursing focus shifts from promoting output to strictly managing input and closely monitoring the patient's fluid status to prevent life-threatening complications.
Answer Rationale: Key Point! The highest priority is Monitoring strict intake and output with fluid restriction. This is the foundational intervention for managing oliguric AKI. It allows the nurse to calculate the patient's daily fluid allowance (often "insensible losses + urine output"), prevent fluid volume excess, and provide critical data for medical management. Failure to do this can rapidly lead to pulmonary edema, hypertension, and heart failure.
Distractor Analysis:
Option 1 (Encourage increased fluid intake): This is contraindicated in the oliguric phase. Adding more fluid to a system that cannot excrete it will worsen fluid overload and hypertension.
Option 2 (Administer diuretics to increase urine output): While diuretics like furosemide may be used in some cases, they are not a first-line or priority intervention. In established oliguric AKI, especially if due to acute tubular necrosis (ATN), the nephrons are damaged and may not respond to diuretics. The priority is fluid management, not forced diuresis, which could lead to electrolyte imbalances.
Option 3 (Provide a high-protein diet): This is incorrect. In AKI, protein intake is often restricted to reduce the production of nitrogenous waste products (like BUN) that the kidneys cannot clear, thereby slowing the progression of uremia. A high-protein diet would increase the metabolic burden.
Related Concepts: The management of AKI follows the phases: Oliguric, Diuretic, and Recovery. Interventions change based on the phase. In the diuretic phase, the priority shifts to monitoring for dehydration and electrolyte losses (like hypokalemia) as urine output increases dramatically.
Monitor for hypovolemia & electrolyte depletion (K+, Na+)
Adequate fluid & electrolyte replacement
Recovery
Gradual return of renal function
Continued monitoring, support for nutritional rebuilding
Gradual increase to normal protein intake
Side-by-Side Comparison!
Condition
Urine Output Concern
Primary Fluid Management
Rationale
Oliguric AKI
Too little output
Restrict fluid intake
Prevent volume overload, pulmonary edema
Diabetes Insipidus (DI)
Too much dilute output
Replace fluid losses
Prevent severe dehydration and hypernatremia
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Too little output (concentrated urine)
Restrict fluid intake
Correct dilutional hyponatremia
Anatomy, Physiology & Pharmacology Points
Physiology: The oliguric phase in AKI often results from acute tubular necrosis (ATN), where ischemic or toxic damage to the renal tubules impairs filtration and reabsorption.
Lab Values: Monitor Elevated BUN & Creatinine, Hyperkalemia (K+ >5.0 mEq/L), and metabolic acidosis.
Pharmacology: Diuretics (e.g., furosemide) are used with caution. Watch out for confusion! They do not treat the underlying kidney injury but may help manage fluid overload if some renal function remains.
Memory Tips
Oliguric = "Hold On": Hold onto the fluids (restrict them)!
Diuretic = "Let Go": Let go of the fluids (replace them)!
Think of the kidney in AKI as a clogged drain. Pouring more water (increasing fluids) into a clogged drain only causes a spillover (pulmonary edema). First, you must stop the flow and measure what's going in and out.
High-Frequency NCLEX Topics
The NCLEX loves to test priority-setting in renal failure. Remember the hierarchy: Airway, Breathing, Circulation (ABCs). Fluid overload from AKI directly threatens Breathing (pulmonary edema) and Circulation (hypertension, heart failure). Therefore, interventions that prevent or detect these complications (like strict I&O) are always high priority.
Watch Out for Question Variations!
Instead of asking for the priority intervention, the question might ask: "The nurse is reviewing lab results for a patient with oliguric AKI. Which finding requires immediate intervention?" Answer: Potassium 6.2 mEq/L (risk of fatal cardiac arrhythmia).
The scenario could shift to the diuretic phase: "A patient with AKI now has a urine output of 250 mL/hr. What is the nurse's priority action?" Answer: Monitor for signs of hypovolemia (tachycardia, hypotension) and electrolyte loss.
Nursing Clinical Practice GuideClinical Scenario: You are assigned to Mr. Johnson, a 68-year-old patient admitted with sepsis, now diagnosed with oliguric AKI (urine output 150 mL over the last 12 hours). He has mild peripheral edema, crackles in his lung bases, and a blood pressure of 158/92 mmHg.
Fluid Management: Collaborate with the provider to establish a daily fluid restriction (e.g., 1000 mL + previous day's urine output). Use a graduated pitcher for oral fluids. Mark all IV lines clearly with infusion rates.
Monitoring: Document I&O meticulously. Calculate the net fluid balance every shift (Intake - Output). Report a positive balance >500 mL in 24 hours.
Safety: Monitor for complications of fluid overload: escalating dyspnea, orthopnea, pink frothy sputum (pulmonary edema), and worsening hypertension.
Electrolyte Management: Monitor serum potassium levels closely. Implement a low-potassium diet and be prepared for emergency interventions (e.g., calcium gluconate, insulin/glucose, kayexalate) if hyperkalemia occurs.
Patient Safety and Precautions:
Contraindication: Do not administer NSAIDs (e.g., ibuprofen) or other nephrotoxic drugs.
Medication Caution: If diuretics are ordered, administer carefully and monitor for ototoxicity (with loop diuretics like furosemide) and drastic electrolyte shifts.
Key Monitoring: Daily weights must be done on the same scale, at the same time (morning), with the patient wearing similar clothing. A weight gain of 1 kg ≈ 1 liter of fluid retention.
Nursing Procedure & Medication FlowStrict I&O Procedure:
1. Intake: Measure ALL sources: Oral fluids (use a graduated cup), IV fluids (including flushes and piggybacks), tube feedings, and IV medications in fluid volumes.
2. Output: Measure ALL sources: Urine (via catheter or urinal/commode), vomitus, diarrhea, wound drainage (e.g., Jackson-Pratt drain), and gastric suction.
3. Documentation: Record amounts immediately. Total at the end of each shift and 24-hour period. Compare intake vs. output and vs. the prescribed fluid restriction.
A Word from Your Senior Nurse: "Managing a patient with oliguric AKI is a test of your vigilance and precision. That I&O sheet isn't just paperwork—it's a real-time map of your patient's internal fluid landscape. Catching a trend of positive fluid balance early allows you to intervene before the patient needs emergent dialysis or intubation. In clinicals and on the NCLEX, when you see 'oliguric' and 'AKI' together, your brain should immediately flash: RESTRICT FLUIDS, MEASURE EVERY DROP. This foundational skill saves lives."
Acute Kidney Injury — A sudden decline in kidney function, leading to the retention of nitrogenous waste products and dysregulation of fluid and electrolytes.
Oliguria — A clinically significant reduction in urine output, typically defined as less than 400 mL per 24 hours in adults.
Fluid Restriction — A therapeutic limitation of total daily fluid intake, calculated based on insensible losses plus measured output, to prevent fluid volume excess.
Intake and Output (I&O) — The precise measurement and recording of all fluids entering and leaving the body, a critical nursing assessment for patients with fluid balance issues.
Hyperkalemia — An elevated serum potassium level (>5.0 mEq/L), a life-threatening complication of AKI that can cause cardiac arrhythmias.