A client who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?
Neurologic status
Urine volume
Cardiac rhythm
Calcium level
The Correct Answer is C
A. Neurologic status is important to monitor but is not directly related to evaluating calcium gluconate's effect on hyperkalemia.
B. Urine volume would not directly reflect the immediate effects of calcium gluconate in managing hyperkalemia.
C. Calcium gluconate is given to protect the heart from the effects of hyperkalemia by stabilizing the cardiac membrane. Monitoring the cardiac rhythm is essential to assess the effectiveness of the treatment.
D. The calcium level is relevant for monitoring the calcium treatment, but cardiac rhythm is a more immediate indicator of its effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The primary concern in this scenario is urinary retention, which can lead to kidney dysfunction (indicated by elevated BUN and creatinine). The priority intervention is relieving the retention by inserting a Foley catheter, which will help restore normal urinary output and prevent further complications.
B. MRI is not an immediate priority when the client is at risk for kidney damage due to urinary retention.
C. While IV fluids may be necessary, the first priority is relieving the obstruction causing urinary retention.
D. Drawing blood is important for assessing the client's condition but is not as urgent as managing urinary retention.
Correct Answer is B
Explanation
A. The excitement of family does not indicate an infection risk. Emotional support can aid recovery.
B. Handling cat litter, which can contain bacteria, is a potential source of infection. Given the client's sternal wound, exposure to such bacteria increases the risk of infection, including sepsis.
C. Attending a party may present social interaction risks, but it is not as directly related to infection risk as handling cat litter.
D. Having the water turned on does not pose a significant risk for infection or sepsis.
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