A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?
Provide a diet high in protein.
Provide ibuprofen for retroperitoneal discomfort.
Monitor intake and output hourly
Encourage the client to consume at least 2 L of fluid daily
The Correct Answer is C
A. Provide a diet high in protein.
During the oliguric phase of acute kidney injury (AKI), there is a risk of electrolyte imbalances, including elevated levels of blood urea nitrogen (BUN) and creatinine. Restricting protein intake is often recommended during this phase to manage azotemia and prevent the accumulation of waste products that the kidneys may struggle to excrete.
B. Provide ibuprofen for retroperitoneal discomfort.
Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in AKI. They can further compromise renal function and may contribute to acute tubular necrosis. NSAIDs can also affect renal blood flow, leading to worsening kidney function.
C. Monitor intake and output hourly.
Monitoring intake and output (I&O) is a critical nursing intervention during the oliguric phase of AKI. Hourly monitoring helps assess renal function, fluid balance, and the effectiveness of interventions. It allows for early detection of changes that may require prompt intervention.
D. Encourage the client to consume at least 2 L of fluid daily.
In the oliguric phase of AKI, fluid intake is often restricted to prevent fluid overload. Encouraging excessive fluid intake may contribute to fluid retention and worsen the oliguria. Fluid management is carefully regulated based on the individual client's needs and renal function.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Yogurt:
Yogurt is not a significant source of iron. While yogurt provides various nutritional benefits, it is not considered an iron-rich food.
B. Oranges:
Oranges are a good source of vitamin C, which enhances the absorption of non-heme iron from plant-based foods. However, oranges themselves do not contain substantial amounts of iron. The combination of vitamin C-rich foods with iron-rich foods can be beneficial for iron absorption.
C. Turnips:
Turnips are a vegetable that, while nutritious, is not particularly high in iron. Additionally, the iron in plant-based foods like turnips is non-heme iron, which is less easily absorbed by the body compared to heme iron found in animal products.
D. Roast beef:
Roast beef is a good source of heme iron, which is more easily absorbed by the body. Red meat, such as roast beef, is a valuable dietary source of iron, especially for individuals with iron deficiency.
Correct Answer is D
Explanation
A. Clean the perineum from front to back.
After arranging the sterile items, the next step involves preparing the client for catheter insertion, which includes cleaning the perineum from front to back using appropriate techniques to minimize the risk of infection.
B. Lubricate the catheter.
Following the preparation of the client, the next step involves lubricating the catheter before insertion. Lubrication facilitates the smooth and atraumatic insertion of the catheter.
C. Explain to the client that she will feel temporary discomfort.
Providing information and preparing the client for the procedure is an important aspect, but it typically follows the physical preparation steps. Explaining to the client about potential discomfort should be done before the procedure but after the necessary physical preparations are complete.
D. Arrange the sterile items on the sterile field.
This is the first action to be taken. It involves preparing all the necessary sterile items on a sterile field, ensuring that everything needed for the catheter insertion procedure is organized and ready to maintain aseptic technique.
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