A nurse is caring for a client who has a diagnosis of acute glomerulonephritis. Which of the following should be reported immediately to the provider?
Urinary output of 280 mL during previous 8 hr
Pedal edema
Hematuria
Blood pressure 162/90 mm Hg
The Correct Answer is D
a) Urinary output of 280 mL during previous 8 hr: This output is within normal limits for an adult, so it does not require immediate reporting.
b) Pedal edema: Edema can occur with glomerulonephritis due to fluid retention, but it is not the most urgent sign.
c) Hematuria: Hematuria is a common finding in glomerulonephritis and does not necessarily require immediate intervention unless severe.
d) Blood pressure 162/90 mm Hg: A blood pressure of 162/90 mm Hg is high and could indicate worsening renal function or complications that require immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a) "I will bend at my knees if I need to pick something up off of the floor." This statement shows an understanding of the importance of avoiding bending over at the waist post-surgery, which can increase intraocular pressure and disrupt the healing process.
b) "I can begin lying on my operative side 24 hours after my surgical procedure." Lying on the operative side should be avoided to prevent pressure on the healing eye.
c) "I will take a dose of aspirin if I have pain in the area of my eyebrow." Aspirin should generally be avoided after cataract surgery due to its anticoagulant effects, which may increase the risk of bleeding.
d) "I can pick up a sack of groceries that weighs 15 pounds." Lifting heavy objects is discouraged after cataract surgery to avoid putting pressure on the eye and affecting healing.
Correct Answer is C
Explanation
a) Leaving the bed in the highest position: This could create a fall risk for the visually impaired person, so it is not an appropriate intervention.
b) Leaving the radio on all the time to help the patient know the time of day: While this may provide some information, it is not the most effective approach for supporting a visually impaired client.
c) Announcing your presence when you enter and leave the room: This is an essential intervention to orient a visually impaired person and help them understand the environment.
d) Keeping the door closed: This could pose a safety risk by limiting the client’s ability to orient to the surroundings. It is generally better to keep doors open for better access and awareness.
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