A nurse is caring for a client with diabetic nephropathy who has developed chronic kidney disease stage 4. Which nursing intervention should be the priority?

In stage 4 chronic kidney disease secondary to diabetic nephropathy, fluid and electrolyte balance becomes critically important as kidney function is severely compromised.

Core Nursing Explanation Key Concept Analysis: This question assesses the ability to prioritize nursing care for a patient with Chronic Kidney Disease (CKD) Stage 4, a complication of Diabetic Nephropathy. The core theme is Maslow's Hierarchy of Needs and the ABCs (Airway, Breathing, Circulation). In advanced CKD, the kidneys' ability to regulate fluid, electrolytes, and waste products is severely impaired, leading to life-threatening complications like Hypervolemia, Hypertension, Hyperkalemia, and Uremia. The priority intervention must address the most immediate physiological threat to survival.

Answer Rationale: Key Point! The correct answer is ② Monitor fluid balance and restrict sodium intake. In CKD Stage 4 (GFR 15-29 mL/min), the kidneys cannot adequately excrete sodium and water. This leads to fluid overload, which can cause Pulmonary edema (compromising breathing), severe hypertension (increasing the risk of stroke or heart failure), and peripheral edema. Monitoring fluid balance (intake/output, daily weights) and restricting sodium are fundamental, life-sustaining interventions to prevent these acute complications. This directly addresses the physiological need for effective circulation and gas exchange.

Distractor Analysis:
Watch out for confusion! ① Encourage increased protein intake to prevent muscle wasting: This is contraindicated in advanced CKD. A low-protein diet is typically prescribed to reduce the buildup of nitrogenous waste products (BUN, creatinine) and slow the progression of kidney damage. High protein intake would increase the kidneys' workload and accelerate uremia.
Watch out for confusion! ③ Administer insulin as prescribed to maintain blood glucose levels: While Glycemic control is crucial in diabetic nephropathy to prevent further kidney damage, it is a chronic management priority, not the acute physiological priority for a patient in Stage 4 CKD. Uncontrolled fluid overload or hyperkalemia poses a more immediate threat to life than a transiently elevated blood glucose level in this context.
Watch out for confusion! ④ Provide education about foot care and daily inspection: Foot care education is a very important secondary prevention measure for patients with diabetes to prevent ulcers and amputations. However, it addresses a safety need that is lower on the priority scale than the imminent physiological threats (fluid/electrolyte imbalance) present in advanced CKD.

Related Concepts: Prioritization in nursing always follows the principle of addressing actual threats to life (ABCs) before potential threats, and physiological needs before safety/educational needs. In renal failure, think "FLEE": Fluid overload, Lytes (Electrolytes - especially K+), Elimination (of waste - uremia), and Erythropoietin (anemia). Fluid and electrolyte issues are often the most urgent. Concept Summary

Concept

Key Point in CKD Stage 4

Pathophysiology

Severely reduced GFR ( 임상 시나리오 Nursing Clinical Practice Guide Clinical Scenario: You are assigned to Mr. Johnson, a 58-year-old with a 20-year history of Type 2 Diabetes Mellitus (DM) and diagnosed Diabetic Nephropathy. He was admitted with fatigue, swelling in his ankles (pitting edema +2), and shortness of breath on exertion. His labs show: Serum Creatinine 3.8 mg/dL, eGFR 18 mL/min/1.73m² (CKD Stage 4), Potassium 5.6 mEq/L. Blood pressure is 168/96 mmHg. Nursing Intervention Strategy: Assessment (The First Priority): Respiratory: Auscultate lung sounds every 4 hours. Listen for crackles (rales) starting at the bases, indicating pulmonary edema. Cardiovascular/Fluid Status: Obtain daily weights at the same time, with the same scale, and wearing the same clothing. This is the most sensitive indicator of fluid gain/loss. Measure strict Intake and Output (I&O). Assess for jugular vein distension (JVD) and degree of peripheral edema. Vital Signs: Monitor BP and heart rate frequently. Hypertension is both a cause and consequence of fluid overload. Lab Monitoring: Track serum electrolytes, especially potassium and sodium, and renal function (BUN, Creatinine). Planning & Implementation: Fluid Management: Collaborate with the dietitian and provider to establish a daily fluid restriction (e.g., 1500 mL/day). Educate the patient on counting all fluids (ice chips, gelatin, soup). Provide mouth care to alleviate thirst. Dietary Management: Enforce a renal diet: Low sodium ( 마이메르시로 국가고시 완벽 대비 기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요. 무료로 시작하기 App Store Google Play 학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.