A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?
Administer antibiotics.
Encourage increased fluid intake.
Encourage frequent ambulation.
Obtain weight weekly.
The Correct Answer is A
Choice A Reason:
Administering antibiotics is a primary intervention for AGN when it is caused by a bacterial infection, such as post-streptococcal glomerulonephritis. Antibiotics help eliminate the infection and prevent further damage to the glomeruli.
Choice B Reason:
Encouraging increased fluid intake is not typically recommended for AGN, especially if the client has oliguria or edema, which are common in this condition. Fluid intake may need to be restricted to prevent fluid overload and worsening of hypertension.
Choice C Reason:
Frequent ambulation is not a priority intervention for AGN. While maintaining mobility is important, it does not directly address the renal inflammation or potential complications associated with AGN.
Choice D Reason:
Obtaining weight weekly is important for monitoring fluid status, but it is not the primary intervention. Daily weight measurements are more indicative of fluid retention or loss and are essential for closely monitoring the client's fluid balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Effective hand hygiene is the most important measure to prevent the transmission of hepatitis A, as the virus can be spread through close personal contact and by eating food or drinking water handled by someone who is infected¹. Handwashing with soap and water after using the bathroom, changing diapers, and before preparing or eating food is crucial.
Choice B reason: While avoiding raw foods can help prevent the transmission of various foodborne illnesses, hepatitis A is not commonly associated with raw foods unless they are contaminated during handling after cooking. However, it is still a good practice to avoid raw or undercooked foods in areas where hepatitis A is common.
Choice C reason:
Hepatitis A virus is primarily transmitted via the fecal-oral route, not through sexual contact. However, barrier protection can reduce the risk of transmission for many other infections, including other types of viral hepatitis that are sexually transmitted.
Choice D reason:
Eating at fast food restaurants is not inherently risky for hepatitis A transmission unless the food or water is contaminated. It is more important to ensure that all food is properly handled and cooked, regardless of the dining establishment.
Correct Answer is D
Explanation
Choice A reason: Positive Trousseau's sign
Trousseau's sign is indicative of hypocalcemia, not CTS. It is elicited by inflating a blood pressure cuff on the upper arm to above systolic pressure for 3 minutes. A positive sign is characterized by carpal spasm, which is not related to CTS.
Choice B reason: Cool extremities
Cool extremities can be a result of various conditions, including peripheral vascular disease or hypothyroidism. They are not a specific indicator of CTS, which primarily affects nerve function rather than blood circulation or temperature regulation.
Choice C reason: Decreased radial pulse
A decreased radial pulse is not typically associated with CTS. It may indicate a cardiovascular issue or a blockage in the radial artery, which would require further investigation unrelated to CTS.
Choice D reason: Positive Phalen's sign
Phalen's sign is a diagnostic test for CTS. The test is performed by having the patient flex their wrist maximally and hold the position for about 60 seconds. A positive Phalen's sign, which includes numbness and tingling in the thumb, index finger, middle finger, and the radial half of the ring finger, is indicative of CTS. This occurs due to increased pressure on the median nerve when the wrist is in flexion.
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