# A nurse is caring for a patient with acute kidney injury (AKI) in the oliguric phase. Which nursing intervention should be the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541372 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a patient with acute kidney injury (AKI) in the oliguric phase. Which nursing intervention should be the highest priority? ## 보기 1. Encourage increased fluid intake to promote kidney function 2. Monitor electrolyte levels and implement fluid restrictions **✔ 정답** 3. Administer diuretics to increase urine output 4. Provide a high-protein diet to prevent muscle wasting **정답: 2** ## 해설 In the oliguric phase of AKI, kidneys cannot filter waste or regulate fluids/electrolytes, so monitoring electrolytes and restricting fluids prevents life-threatening complications like hyperkalemia and pulmonary edema. Other options (increasing fluids, diuretics, high-protein diet) can worsen fluid overload or azotemia. ## 심화 해설 Understanding Acute Kidney Injury (AKI) & the Oliguric Phase Acute Kidney Injury represents a sudden decline in kidney function, leading to the accumulation of waste products and the inability to regulate fluid and electrolyte balance. The clinical course often includes an oliguric phase, characterized by a urine output of less than 400 mL/day. During this phase, the kidneys have lost their ability to effectively filter blood and excrete fluid. The underlying pathophysiology involves tubular damage, intratubular obstruction, and reduced glomerular filtration rate. Because the kidneys cannot remove excess volume, continuing to add fluid to the system without careful monitoring can rapidly lead to fluid volume overload, a critical complication that can precipitate hypertension, pulmonary edema, and heart failure. The Brazilian Society of Nephrology guidelines emphasize that managing these patients requires meticulous attention to hemodynamic and volume status, as the nephrologist's role includes preventing iatrogenic complications from fluid mismanagement [1]. Priority Nursing Intervention: Fluid Restriction & Monitoring The highest priority nursing intervention is to monitor strict intake and output (I&O) with fluid restriction. This is a cornerstone of non-dialysis kidney support therapy. The rationale is grounded in the principle of balancing fluid intake with the patient's drastically reduced output and insensible losses. Accurate I&O monitoring provides the essential data needed to guide fluid prescription and prevent overload. Fluid restriction is typically calculated to replace only insensible losses (from skin and respiration, roughly 500-600 mL/day) plus the volume of any measurable output (urine, vomitus, diarrhea). This precise management is a direct application of volume management principles, which are critical for patients with kidney dysfunction to avoid the cascading negative effects of hypervolemia on both cardiac and renal function [2]. Analysis of Incorrect Options - **Option 1: Encourage increased fluid intake to promote kidney function.** This is contraindicated in the oliguric phase of AKI. The primary problem is not a lack of fluid, but the kidney's inability to process it. Forcing fluids will not "flush out" the kidneys; instead, it will dangerously expand the intravascular volume, leading to dilutional hyponatremia, hypertension, and pulmonary edema. The goal is to maintain euvolemia, not to challenge the already injured kidneys with a fluid load they cannot handle. - **Option 2: Administer diuretics to increase urine output.** While loop diuretics like furosemide are sometimes used in AKI, their role is primarily to manage fluid overload, not to treat the underlying kidney injury or improve kidney function. In the oliguric phase, the tubules are often unresponsive to diuretics. Administering them is a medical, not an independent nursing, intervention and is not the highest initial priority. The priority nursing action is to first establish a strict monitoring baseline to determine the severity of fluid imbalance before any pharmacological intervention is considered. Evidence suggests that diuretic use does not improve patient-centered outcomes like mortality or renal recovery in AKI. - **Option 3: Provide a high-protein diet to prevent muscle wasting.** This is incorrect for the oliguric phase. A high-protein diet increases the production of nitrogenous waste products (blood urea nitrogen), which the injured kidneys cannot effectively excrete. This exacerbates azotemia and uremia. Nutritional therapy in AKI is carefully calibrated; during the oliguric phase, the focus is on providing adequate calories from carbohydrates and fats to prevent catabolism while restricting protein to minimize uremic toxin buildup. Once the patient enters the diuretic phase or begins dialysis, protein intake is liberalized. Clinical Application and Evidence Synthesis The synthesis of evidence from the guidelines and the volume management summary reinforces that fluid control is the linchpin of AKI management. The hospital nephrology assistance guide details that non-dialysis supportive care, which is largely nurse-driven, centers on strict hemodynamic and fluid balance monitoring to prevent iatrogenic volume overload [1]. This aligns directly with the best-practice evidence for volume management in patients with complex cardiac and renal comorbidities, which emphasizes a systematic, evidence-based approach to fluid assessment and restriction to prevent decompensation [2]. For the NCLEX-RN examinee, this scenario tests the ability to recognize that in a state of severely impaired excretion, restricting intake is a fundamental safety principle that takes precedence over promoting intake, stimulating output with medications, or increasing metabolic waste production through diet. The nurse's role is to protect the patient from the immediate, life-threatening consequence of fluid overload. References (research sources) - [1]Guidelines for hospital nephrology assistance from the Brazilian Society of Nephrology (BSN).GuidelineYounes-Ibrahim M, Rocha E, Reis T, Colares VS, Lima EQ, Andrade LDC, Rosa EC, Cardoso HS, Thomé F, Ponce D, Suassuna JHR, Yu L. (2025) · DOI: 10.1590/2175-8239-jbn-2024-0239en - [2]Best Evidence Summary for Volume Management of Patients With Heart and Kidney Comorbidity.Research articleAoli H, Xia C, Xujing Z, Qiaozhen Y, Yeyao Y, Jiehui F. (2026) · DOI: 10.1002/nop2.70544 ## 임상 시나리오 Clinical Management of Oliguric Acute Kidney Injury In the oliguric phase of AKI, the kidneys lose their ability to excrete waste and regulate volume. Nursing care prioritizes preventing life-threatening complications from electrolyte derangements and fluid overload. Priority Assessment & Monitoring - **Electrolyte Surveillance:** Monitor serum potassium, sodium, and calcium levels at least every 6-12 hours. The most immediate danger is hyperkalemia (K+ >5.0 mEq/L), which can precipitate fatal cardiac arrhythmias. Obtain continuous cardiac monitoring to detect peaked T-waves, widened QRS, or ventricular fibrillation. - **Fluid Balance:** Implement strict intake and output (I&O) charting. Daily fluid allowance is typically calculated as insensible losses (400-500 mL) plus the previous 24-hour urine output. Daily weights are essential; a gain of 1 kg roughly equates to 1 L of fluid retention. - **Vital Signs:** Assess for hypertension, tachycardia, tachypnea, and crackles on lung auscultation, which indicate fluid volume excess and potential pulmonary edema. Interventions & Management - **Fluid Restriction:** Enforce the prescribed fluid limit, distributing it evenly over 24 hours. Provide oral care to manage thirst without increasing intake. Educate the patient and family on the rationale to ensure adherence. - **Dietary Modification:** Restrict dietary potassium (e.g., bananas, oranges, potatoes) and sodium. Protein intake is typically restricted to 0.6-0.8 g/kg/day to minimize azotemia while providing adequate calories to prevent catabolism. Consult a dietitian for a renal diet plan. - **Medication Safety:** Withhold nephrotoxic drugs (NSAIDs, aminoglycosides, contrast dye). Administer prescribed potassium-binding agents (e.g., sodium polystyrene sulfonate) or prepare for emergency dialysis if hyperkalemia is refractory or severe. - **Skin Integrity:** The patient is at high risk for edema and pressure injuries. Implement a turning schedule and use pressure-relieving devices. Patient Education & Psychosocial Support - Explain the temporary nature of fluid and dietary restrictions to reduce anxiety. The oliguric phase may last 1-3 weeks, and adherence is critical to avoid dialysis. - Instruct the patient to report symptoms of fluid overload immediately: shortness of breath, orthopnea, or sudden weight gain. - Provide emotional support, as the sudden onset of a critical illness and strict regimen can be distressing. Coordinate with social work and chaplaincy services as needed. ## 핵심 개념 - **Oliguric Phase** — The phase of acute kidney injury characterized by a urine output of less than 400 mL/day, resulting in fluid retention, electrolyte imbalances, and accumulation of metabolic waste. - **Hyperkalemia** — A serum potassium level greater than 5.0 mEq/L, a critical complication of kidney failure that can cause life-threatening cardiac arrhythmias and cardiac arrest due to altered myocardial conduction. - **Fluid Restriction** — A medical intervention limiting daily fluid intake to prevent volume overload, hypertension, pulmonary edema, and heart failure in patients with impaired kidney function. - **Azotemia** — The accumulation of nitrogenous waste products, such as urea and creatinine, in the blood due to decreased glomerular filtration rate. - **Glomerular Filtration Rate (GFR)** — The rate at which blood is filtered by the glomeruli of the kidneys; a severely reduced GFR in AKI leads to the retention of fluids, electrolytes, and waste products. ## 같은 주제 문제 - [A nurse is assessing a patient with suspected acute kidney injury (AKI). 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