A nurse is caring for a client on a pediatric unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
• Restricting salt in the diet is more relevant in chronic kidney disease or hypertension management, not in acute hydronephrosis. The main concern here is obstruction and impaired urine flow rather than sodium retention, so reducing salt intake would not address the acute problem.
• Encouraging fluid intake helps promote urine flow and reduces the risk of worsening obstruction or stone formation. Adequate hydration supports kidney perfusion and prevents highly concentrated urine, which could aggravate symptoms and kidney stress.
• Elevating the legs is helpful in conditions involving edema or poor venous return, but it does not improve urinary obstruction or hydronephrosis. Since the client’s primary concern involves kidney drainage, this intervention would not target the actual pathology.
• Administering pain medication is important because hydronephrosis often causes significant flank or back pain. Pain control improves comfort and also reduces stress-related physiological responses such as increased blood pressure or tachycardia.
• Monitoring blood glucose levels is essential in diabetic clients, but there is no evidence of diabetes in this case. The more urgent focus is on monitoring kidney function and hemodynamic stability, making glucose monitoring less relevant here.
• Renal calculi can be an underlying cause of hydronephrosis, but the ultrasound shows hydronephrosis directly rather than confirming stones. The correct condition to identify is hydronephrosis itself, which describes the kidney swelling from obstructed urine flow.
• Benign prostatic hyperplasia is a common cause of urinary obstruction in older males, but this is a pediatric client. The presentation is more consistent with urinary tract obstruction leading to hydronephrosis rather than BPH.
• Hydronephrosis is confirmed on ultrasound, showing urine backflow into the kidneys due to obstruction. The client’s urinary difficulty, flank pain, and rising BUN/creatinine levels support this diagnosis as the most likely condition.
• Chronic glomerulonephritis usually presents with proteinuria, hematuria, and persistent hypertension over time. The acute urinary retention and hydronephrosis on imaging do not align with this condition, making it less likely.
• Monitoring the skin condition is useful for immobility or fluid balance concerns, but it does not reflect kidney function or the effectiveness of interventions for hydronephrosis. Therefore, it is not a priority parameter in this scenario.
• Monitoring urine output is critical because it directly reflects kidney function and the effect of relieving obstruction. Any changes in urine volume help determine whether hydronephrosis is improving or worsening.
• Monitoring the respiratory rate can detect systemic illness or pain-related changes, but it is not specific to kidney obstruction. Unless complications like sepsis develop, it is less relevant for tracking hydronephrosis.
• Monitoring the heart rate can help assess pain or stress but does not provide specific information on renal function. Although useful as a general vital sign, it is not as direct as urine output or blood pressure for evaluating progress.
• Monitoring blood pressure is essential because kidney function strongly influences blood pressure regulation through fluid balance and renin-angiotensin activity. Rising blood pressure may indicate worsening renal compromise from hydronephrosis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
- Restricting fluid intake is essential in acute kidney injury (AKI) to prevent fluid overload, as the kidneys are unable to excrete excess fluid efficiently. Maintaining the prescribed fluid restriction helps reduce the risk of pulmonary edema, hypertension, and worsening renal function.
- Monitoring daily weight provides a direct measure of fluid balance and helps detect subtle changes in fluid retention. In AKI, weight gain may indicate fluid accumulation, and tracking it allows timely adjustments in fluid management and treatment interventions.
- Increasing carbohydrate consumption is not directly relevant to managing AKI. Nutritional adjustments may be considered for overall health, but they do not address fluid retention, electrolyte imbalance, or kidney function directly.
- Administering antibiotics is only indicated if there is evidence of infection. The client’s lab values and vital signs do not indicate infection, so antibiotics are not a priority intervention.
- Applying a sterile dressing is appropriate for wound care or infection prevention but does not address the acute renal condition or its complications. It is unrelated to the current management needs of AKI.
- Diabetes mellitus can lead to chronic kidney disease over time, but the acute rise in BUN, creatinine, and potassium, along with hypertension, suggests an acute renal event rather than a chronic endocrine condition.
- Chronic liver disease can cause fluid retention and electrolyte imbalances, but the lab pattern and acute elevation in renal markers point to kidney injury rather than liver pathology.
- Acute kidney injury is characterized by rapid increases in BUN, creatinine, and potassium, along with changes in urine output and blood pressure. The client’s elevated BUN (28→30 mg/dL), creatinine (2.6→2.8 mg/dL), and hyperkalemia (5.2→5.5 mmol/L) confirm AKI as the most likely condition.
- Peritonitis would typically present with abdominal pain, tenderness, fever, and sometimes changes in dialysate if the client is on peritoneal dialysis. These findings are absent in this scenario, making peritonitis unlikely.
- Monitoring temperature is important for detecting infection but does not directly indicate kidney function or fluid status. While useful, it is not the primary parameter for assessing AKI progression.
- Monitoring respiratory rate is essential for general health but only becomes critical if fluid overload or pulmonary edema develops. It is not as direct a measure of renal status as blood pressure or heart rate.
- Monitoring dialysate color is relevant for clients on peritoneal dialysis to detect infection, but there is no mention of peritoneal dialysis in this client’s scenario, making it irrelevant for assessing AKI.
- Monitoring blood pressure is crucial because hypertension is both a cause and complication of AKI. Elevated blood pressure can worsen kidney injury, and tracking it helps guide fluid and medication management.
- Monitoring heart rate is important to assess cardiovascular response to fluid shifts, electrolyte imbalances, and overall hemodynamic stability in AKI. Changes in heart rate can indicate worsening fluid overload or hyperkalemia effects.
Correct Answer is C
Explanation
A. Take phenazopyridine for at least 7 days: Phenazopyridine is a urinary analgesic and does not treat the underlying infection. It should be used only for symptom relief, usually for a short duration, and not as a substitute for the full course of antibiotics.
B. Phenazopyridine may cause photosensitivity: Photosensitivity is not a commonly reported side effect of phenazopyridine. The primary concern with this medication relates to its effects on urine color rather than skin sensitivity to sunlight.
C. Phenazopyridine may change the urine color: Phenazopyridine can turn urine a reddish-orange color, which is harmless but important for patients to understand to avoid alarm. Educating the patient about this expected effect improves adherence and reduces anxiety related to urine discoloration.
D. Take phenazopyridine before sexual course: Phenazopyridine is not indicated as a preventative or prophylactic measure for sexual activity. Its use is for symptomatic relief of urinary discomfort and should be coordinated with the prescribed antibiotic regimen.
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