A nurse is caring for an adolescent who has acute glomerulonephritis. Which of the following actions should the nurse take?
Weigh the client daily.
Increase the client's dietary protein intake.
Assess the client's blood pressure every 8 hr.
Avoid palpating the client's abdomen.
The Correct Answer is A
A. Weigh the client daily: Acute glomerulonephritis commonly causes fluid retention due to impaired renal filtration. Daily weights provide the most accurate assessment of fluid balance and help detect subtle increases in fluid volume that may indicate worsening edema or renal function.
B. Increase the client’s dietary protein intake: Protein intake is often restricted in acute glomerulonephritis to reduce the workload on the kidneys and limit nitrogenous waste production. Increasing protein could worsen azotemia and place additional stress on renal function.
C. Assess the client’s blood pressure every 8 hr: Blood pressure monitoring is important because hypertension is common in acute glomerulonephritis. However, daily weights are a more sensitive and priority measure for detecting fluid overload, which directly contributes to hypertension and edema.
D. Avoid palpating the client’s abdomen: Abdominal palpation is not contraindicated in acute glomerulonephritis. While care should be gentle, avoiding abdominal assessment is unnecessary and does not directly address the primary concerns of fluid balance and renal function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypokalemia: Acute renal failure typically results in impaired potassium excretion, leading to hyperkalemia rather than hypokalemia. Low potassium is not expected and would require investigation for other causes if present.
B. Oliguria: Oliguria, defined as decreased urine output, is a hallmark sign of acute renal failure. The kidneys’ inability to filter and excrete waste products leads to fluid retention, electrolyte imbalances, and accumulation of metabolic waste, making oliguria a key finding.
C. Metabolic alkalosis: Acute renal failure usually causes metabolic acidosis due to the kidneys’ inability to excrete hydrogen ions and reabsorb bicarbonate effectively. Alkalosis is uncommon in this condition unless other factors are present.
D. Hypercalcemia: Impaired renal function in acute renal failure more commonly leads to hypocalcemia due to phosphate retention and decreased vitamin D activation. Hypercalcemia is not a typical feature of acute renal failure.
Correct Answer is B
Explanation
A. "I will include toilet paper that falls into the urine as part of the collected sample.": Contamination of the urine specimen with toilet paper or other foreign material can alter test results and compromise accuracy. The collection container should receive urine only, and any contaminated sample should be discarded and reported.
B. "I will throw out my first urine sample when I start the urine collection.": A 24-hour urine collection begins after discarding the first void to ensure the bladder is empty at the start time. All urine produced after that point, including the final void at 24 hours, is collected to provide an accurate measurement.
C. "I can stop the urine test earlier than 24 hours if I fill up the collection container.": Stopping the collection early results in incomplete data and invalid test results. If the container becomes full, an additional container should be obtained so the full 24-hour collection can be completed.
D. "I can discard urine while I am at school if I keep track of the number of times I void.": Every void during the 24-hour period must be collected regardless of location. Missing any urine output makes the test inaccurate, even if the number of voids is recorded.
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