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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Gum bleeding can be a sign of thrombocytopenia (low platelet count) and is concerning because it indicates a potential for bleeding complications. However, while it's significant, it might not be the most urgent symptom in the context of HIT compared to symptoms indicating acute thrombosis.
B. A hemoglobin level of 14 g/dL is generally within the normal range for most adults. In the context of HIT, this level does not indicate any immediate abnormality or severe issue related to anemia or bleeding, making it less concerning compared to other symptoms that might indicate acute complications.
C. Tachycardia (increased heart rate) and shortness of breath are concerning symptoms in the context of HIT. These symptoms can be indicative of a thrombotic event such as a pulmonary embolism (PE) or deep vein thrombosis (DVT), which are serious complications of HIT. The presence of these symptoms requires urgent evaluation as they suggest possible life-threatening complications.
D. Petechiae are small, pinpoint red or purple spots that appear due to bleeding under the skin, often associated with low platelet counts. While petechiae are a concerning sign and indicate bleeding issues, the presence of tachycardia and shortness of breath generally represents a more immediate threat to the patient's life due to potential thromboembolic events.
Correct Answer is ["0.4"]
Explanation
Volume to administer = (Desired Dose) / (Concentration of available medication). The desired dose is 2,000 units, and the concentration available is 5,000 units/mL. Using the formula, you get 2,000 units / 5,000 units/mL = 0.4 mL.
Therefore, the nurse should administer 0.4 mL of heparin injection to deliver a dose of 2,000 units.
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