A nurse is caring for a 65-year-old patient with acute kidney injury (AKI) in the oliguric phase, with urine output of 200 mL in the past 24 hours. Laboratory results show BUN 80 mg/dL, creatinine 4.2 mg/dL, potassium 5.9 mEq/L, and phosphorus 7.5 mg/dL. Which nursing intervention should be the highest priority?
A 65-year-old patient with acute kidney injury is experiencing oliguria, with urine output of 200 mL in the past 24 hours. Laboratory results show BUN 80 mg/dL, creatinine 4.2 mg/dL, potassium 6.8 mEq/L, and phosphorus 7.5 mg/dL.
1Monitor daily weights and intake/output records
2Assess for signs of hyperkalemia and cardiac dysrhythmias✓ 정답
3Restrict protein intake to reduce nitrogenous waste
4Administer prescribed diuretics to increase urine output
해설
Hyperkalemia (K+ 6.8 mEq/L) poses the most immediate life-threatening risk in AKI oliguric phase, requiring priority assessment for cardiac dysrhythmias. Other interventions are important but address less urgent concerns.
Clinical Judgment
This question tests Prioritization and Risk Recognition. The key is to identify the most life-threatening immediate complication in the Oliguric Phase of acute kidney injury (AKI). Looking at the patient's lab values, Potassium (K+) 6.8 mEq/L is the most prominent abnormal finding. Hyperkalemia can disrupt the electrical stability of the heart and cause fatal arrhythmias, so according to the Airway, Breathing, Circulation (ABC) principle, assessing this condition that threatens Circulation is the highest priority.
Memory Tip:
To remember Hyperkalemia, think "Muscle, EKG, Kidney." Muscle weakness, EKG changes (peaked T waves, widened QRS), and Kidney problems are the main causes. Remember that in AKI patients, "high potassium means the heart is in danger."
KR vs US:
Both Korea and the US recognize the danger of hyperkalemia and emphasize cardiac monitoring. The difference is that the US NCLEX exam places a very strong emphasis on judging "The Most Dangerous" or "The Highest Priority" based on the ABC principle and Immediate Threat to life. Korean exams are similar, but the NCLEX tends to assess this Risk Stratification in more detail.
임상 시나리오
Clinical Practice Guide
The core of nursing care for patients in the oliguric phase of AKI is preventing and managing electrolyte imbalance and fluid overload.
1. Hyperkalemia monitoring: Check serum potassium levels daily, continuous ECG monitoring, and assess for symptoms such as muscle weakness, paresthesia, and bradycardia.
2. Fluid management: Strict intake and output (I&O) recording, daily weight measurement at the same time wearing the same clothes.
3. Dietary management: Restrict high-potassium foods (bananas, oranges, tomatoes, potatoes), restrict foods high in phosphorus (P) (dairy products, legumes, nuts), and limit protein intake as directed by a nephrologist or dietitian.
Caution:
- Option 4 ("Diuretic administration") is a trap. In oliguric AKI, diuretics can further reduce renal blood flow and worsen kidney injury. Diuretics are used cautiously under the judgment of a nephrologist when fluid overload is present.
- In SATA (Select All That Apply) questions asking "necessary nursing interventions for an AKI patient," options 1, 2, and 3 can all be correct interventions. However, in questions asking for the "Highest Priority," you should select the assessment for life-threatening hyperkalemia (option 2).
핵심 개념
Acute Kidney Injury — Acute kidney injury. A condition where kidney function suddenly declines within hours to days. It is divided into the oliguric, diuretic, and recovery stages.
Oliguric Phase — Oliguric phase. A stage of AKI where urine output markedly decreases (typically
Hyperkalemia — Hyperkalemia. A condition where the serum potassium level rises above the normal range (3.5-5.0 mEq/L). It is a major complication of AKI and can disrupt the heart's electrical activity, leading to life-threatening arrhythmias.
Cardiac Dysrhythmia — Cardiac arrhythmia. A condition where the normal heartbeat rhythm is disrupted due to abnormalities in the generation or conduction of electrical impulses in the heart. Hyperkalemia can cause serious arrhythmias such as ventricular fibrillation.
BUN/Creatinine Ratio — The ratio of BUN (Blood Urea Nitrogen) to creatinine. It is an indicator for evaluating kidney function. In AKI, both BUN and creatinine typically rise. This patient's values (BUN 80, Cr 4.2) suggest severe renal impairment.