A nurse is planning care for a client who has pyelonephritis. Which of the following interventions should the nurse include in the plan?

Provide instruction on pelvic muscle exercises.

Administer skeletal muscle relaxants every 6 hr.

Encourage fluid intake.

Monitor vital signs every 8 hr.

Answer and Explanation

The Correct Answer is C

A) Provide instruction on pelvic muscle exercises:
Pelvic muscle exercises are beneficial for urinary incontinence but are not a standard intervention for treating pyelonephritis. Pyelonephritis focuses on managing infection and inflammation of the kidneys rather than strengthening pelvic muscles.

B) Administer skeletal muscle relaxants every 6 hr:
Skeletal muscle relaxants are not typically used in the treatment of pyelonephritis. The focus should be on antibiotics to treat the infection and analgesics for pain relief, rather than muscle relaxants.

C) Encourage fluid intake:
Increasing fluid intake helps flush bacteria from the urinary tract, which can aid in reducing the infection and promoting kidney health. Proper hydration is crucial for clients with pyelonephritis to help manage symptoms and prevent further complications.

D) Monitor vital signs every 8 hr:
While monitoring vital signs is important, it should be done more frequently than every 8 hours, especially in the acute phase of pyelonephritis, to promptly identify any signs of worsening infection or sepsis.

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Correct Answer is D

Explanation

A) Dyspepsia:
Dyspepsia, or indigestion, is a common symptom of peptic ulcer disease, causing discomfort in the upper abdomen. While it is uncomfortable and should be managed, it is not immediately life-threatening and does not require urgent intervention compared to other symptoms.

B) Nausea:
Nausea can be a distressing symptom associated with peptic ulcer disease, often resulting from irritation of the stomach lining. Although it can significantly impact the client’s well-being and appetite, it is not as critical as symptoms indicating active bleeding or more severe complications.

C) Hyperactive bowel sounds:
Hyperactive bowel sounds may be present in peptic ulcer disease due to increased gastrointestinal activity. This finding suggests heightened digestive activity but does not indicate an immediate life-threatening condition that would take precedence over signs of active bleeding.

D) Hematemesis:
Hematemesis, or vomiting blood, is a serious and potentially life-threatening symptom that indicates active gastrointestinal bleeding. This requires immediate medical attention to prevent significant blood loss, shock, and other complications. It is the priority finding because it poses the most immediate risk to the client’s health and stability.

A. Expect optimum visual acuity to return in 4 to 6 weeks, B. Notify the provider if new floaters persist for more than 3 days. C. Take aspirin every 4 to 6 hr for mild discomfort. D. Avoid lifting objects that weigh 9.07 kg (20 lb) or more.

Correct Answer is D

Explanation

A) Expect optimum visual acuity to return in 4 to 6 weeks: While some improvement in vision can be noted soon after cataract surgery, optimal visual acuity typically returns within 1 to 2 months. It's important to set realistic expectations for recovery. Telling the patient to expect optimum visual acuity to return in 4 to 6 weeks provides a more accurate timeframe for complete visual recovery.

B) Notify the provider if new floaters persist for more than 3 days: The presence of new floaters can be a sign of complications such as retinal detachment or vitreous hemorrhage. However, patients are generally advised to notify their provider immediately if they notice any new floaters, flashes of light, or a sudden decrease in vision, rather than waiting for three days. Immediate notification can lead to prompt evaluation and treatment if necessary.

C) Take aspirin every 4 to 6 hr for mild discomfort: Aspirin is generally avoided postoperatively due to its blood-thinning properties, which can increase the risk of bleeding. Instead, non-aspirin pain relievers like acetaminophen are usually recommended to manage mild discomfort after cataract surgery, as they do not carry the same risk of bleeding complications.

D) Avoid lifting objects that weigh 9.07 kg (20 lb) or more: Patients are advised to avoid lifting heavy objects and engaging in strenuous activities after cataract surgery to prevent increased intraocular pressure, which can interfere with healing and potentially cause complications such as bleeding or dislocation of the intraocular lens. This instruction helps ensure the safety and proper healing of the surgical site.

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A nurse is planning care for a client who has pyelonephritis. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

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Correct Answer is D

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Correct Answer is D

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