For a male client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important?
A. Encouraging coughing and deep breathing.
B. Promoting carbohydrate intake.
C. Limiting fluid intake.
D. Providing pain-relief measures.
Correct Answer: C. Limiting fluid intake.
During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Scatter desired beverages throughout the 24-hour period and give various offerings (hot, cold, frozen). Help avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst.
Option A: Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Provide supplemental oxygen if indicated. Maximizes available oxygen for myocardial uptake to reduce cardiac workload and cellular hypoxia.
Option B: Promoting carbohydrate intake may be helpful in ARF but doesn’t take precedence over fluid limitation. Review fluid restriction. Remind the patient to spread fluids over the entire day and to include all fluids (ice) in daily fluid counts. Depending on the cause and stage of ARF, the patient may need to either restrict or increase intake of fluids.
Option D: Controlling pain isn’t important because ARF rarely causes pain. Encourage the patient to observe characteristics of urine and amount, frequency of output. Changes may reflect alterations in renal function and need for dialysis. Establish a regular schedule for weighing. Useful tool for monitoring fluid and dietary needs.
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