A nurse is admitting a client who has acute pyelonephritis. Which of the following assessment findings should the nurse expect? (Select all that apply.)

Tachypnea

Nausea

Hypothermia

Bradycardia

Flank pain

Answer and Explanation

Correct Answer : B,E

A) Tachypnea:
Tachypnea, or rapid breathing, is not a typical symptom of acute pyelonephritis. This condition primarily affects the kidneys and urinary tract, and while it can cause systemic symptoms, tachypnea is more commonly associated with respiratory issues.

B) Nausea:
Nausea is a common symptom of acute pyelonephritis. The infection and inflammation of the kidneys can lead to gastrointestinal symptoms, including nausea and vomiting.

C) Hypothermia:
Hypothermia, or abnormally low body temperature, is not commonly associated with acute pyelonephritis. Patients with this condition are more likely to present with fever rather than hypothermia.

D) Bradycardia:
Bradycardia, or slow heart rate, is not typically seen in acute pyelonephritis. In fact, systemic infections and the associated fever can often lead to an increased heart rate (tachycardia).

E) Flank pain:
Flank pain is a hallmark symptom of acute pyelonephritis. The pain is usually located in the back and sides, near the affected kidney, and can be quite severe. This pain results from the inflammation and infection of the kidney.

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Correct Answer is A

Explanation

A. Administer a dose of subcutaneous epinephrine.: The swelling of the lips and tongue is indicative of angioedema, a serious adverse reaction to captopril. Epinephrine is the first-line treatment for severe allergic reactions or angioedema to quickly counteract the swelling and prevent airway obstruction.

B. Advise the client not to consume grapefruit products.: Grapefruit can interact with some medications, but it is not related to the management of angioedema. This action would be more relevant for drugs metabolized by CYP3A4, not specifically for angioedema.

C. Place warm compresses on both sides of the client's face.: Warm compresses are not appropriate for angioedema and may not address the underlying issue. This action does not manage the immediate, potentially life-threatening reaction caused by captopril.

D. Swab the client's oral mucosa with nystatin suspension.: Nystatin is used for fungal infections of the oral mucosa, not for angioedema. This action does not address the adverse reaction related to captopril.

A. Instruct the client to perform coughing exercises after meals. B. Limit the client's fluid intake to 1,500 mL/day. C. Encourage the client to sit in a chair for 1 hr several times per day. D. Initiate oxygen therapy for the client via nasal cannula at 10 L/min.

Correct Answer is A

Explanation

A) Instruct the client to perform coughing exercises after meals.
Coughing exercises after meals can help clear the airways of mucus, which is beneficial for clients with COPD. Effective airway clearance is crucial to improve breathing and reduce the risk of infections. This intervention can enhance respiratory function and comfort.

B) Limit the client's fluid intake to 1,500 mL/day.
Limiting fluid intake is generally not recommended for clients with COPD unless there is a specific medical reason, such as heart failure. Adequate hydration helps keep mucus thin and easier to expectorate, which is important for respiratory health.

C) Encourage the client to sit in a chair for 1 hr several times per day.
Encouraging the client to sit in a chair helps promote mobility and prevent complications associated with prolonged bed rest. However, while sitting up can improve lung expansion, it is not the most specific or direct intervention to address dyspneic episodes.

D) Initiate oxygen therapy for the client via nasal cannula at 10 L/min.
Administering oxygen at a high flow rate like 10 L/min is not typically appropriate for clients with COPD due to the risk of depressing their respiratory drive. Oxygen therapy should be carefully titrated and monitored based on the client's needs and blood gas levels.

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A nurse is admitting a client who has acute pyelonephritis. Which of the following assessment findings should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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