A client diagnosed with acute glomerulonephritis has pitting edema in both feet, and has had 300 mL of urine output in the last 24 hours. The nurse should monitor this client for which complication associated with this finding?

Fluid volume deficit

Bradycardia

Hypertension

Hyperglycemia

Answer and Explanation

The Correct Answer is C

A.   Fluid volume deficit, or dehydration, occurs when the body loses more fluid than it takes in. In this case, the patient has very low urine output, indicating that the kidneys are not excreting enough fluid. Despite the low urine output, the presence of pitting edema suggests that the patient is actually retaining fluid rather than losing it.
B.   Bradycardia is defined as a heart rate slower than 60 beats per minute. While electrolyte imbalances and fluid imbalances can affect heart rate, bradycardia is not the primary concern associated with the combination of pitting edema and low urine output in this situation.
C.   Hypertension (high blood pressure) is a common complication in acute glomerulonephritis. The condition often leads to fluid retention due to reduced kidney function and increased sodium and fluid retention. The presence of pitting edema and very low urine output suggests that the kidneys are not effectively removing excess fluid, which can lead to increased blood pressure.
D.   Hyperglycemia refers to elevated blood glucose levels. Acute glomerulonephritis is not directly associated with hyperglycemia. While patients with diabetes can develop renal issues, hyperglycemia itself is not a typical direct complication of acute glomerulonephritis.

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Correct Answer is A

Explanation

A. The late-phase response in asthma is characterized by a delayed and prolonged inflammatory reaction that can occur 4 to 6 hours after exposure to a trigger. It involves the recruitment of additional inflammatory cells, such as eosinophils and T cells, which contribute to ongoing airway inflammation, increased mucus production, and bronchoconstriction. This phase often leads to a return of symptoms or worsening of symptoms after the initial relief provided by a rescue inhaler.
B. The late-phase response does not typically respond as well to rescue inhalers (such as albuterol) as the early-phase response does. Rescue inhalers are primarily effective for the immediate, bronchospastic component of asthma (early-phase response).
C. The late-phase response occurs as part of the natural progression of asthma inflammation and is not necessarily related to improper use of a rescue inhaler. Even with proper use of a rescue inhaler, the late-phase response can still occur due to the underlying inflammatory processes.
D. The late-phase response can occur even if the trigger is no longer present. It is related to the ongoing inflammatory process rather than continued exposure to the trigger. Although continued exposure to triggers can exacerbate symptoms, the late-phase response can still occur independently of further exposure.

A. "The sputum I have been coughing up is pink." B. "I feel short of breath when I lie down flat." C. "The nurse I had yesterday said she could hear fluid in my lungs." D. "Both of my legs are so swollen."

Correct Answer is D

Explanation

A. Pink, frothy sputum is typically associated with left-sided heart failure and pulmonary edema. This occurs when fluid backs up into the lungs due to left-sided heart failure. Since the question pertains to right-sided heart failure, this statement is not consistent with that condition.

B. Feeling short of breath when lying flat is known as orthopnea and is more commonly associated with left-sided heart failure. It occurs due to fluid shifting into the lungs when supine, which aggravates pulmonary congestion. This statement is not consistent with right-sided heart failure.
C. Hearing fluid in the lungs typically indicates left-sided heart failure, where fluid backs up into the pulmonary circulation, causing pulmonary edema. This symptom is associated with left-sided heart failure rather than right-sided heart failure.
D. Swelling of the legs, also known as peripheral edema, is a hallmark of right-sided heart failure. This occurs because the right side of the heart is unable to effectively pump blood out to the lungs, leading to fluid accumulation in the systemic venous circulation and resulting in swelling in the lower extremities and sometimes the abdomen

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A client diagnosed with acute glomerulonephritis has pitting edema in both feet, and has had 300 mL of urine output in the last 24 hours. The nurse should monitor this client for which complication associated with this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is performing an admission assessment on a client who is being admitted for right- sided heart failure. Which statement made by the patient would be consistent with right-sided heart failure?

Correct Answer is D

Explanation

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