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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "I should choose cold foods over warm foods.": Cold foods are not necessarily better than warm foods for someone with ulcerative colitis. The choice of temperature depends on individual tolerance, but there is no specific recommendation that cold foods are preferable. Warm, easily digestible foods can also be soothing and well-tolerated.
B) "I should follow a low-protein diet.": This is not an accurate recommendation for ulcerative colitis. Protein is essential for healing and maintaining muscle mass, especially if the client is experiencing malnutrition or weight loss due to the disease. A balanced diet with adequate protein is important for overall health.
C) "I should increase my fiber intake to 35 grams a day.": High fiber intake can be problematic for those with active ulcerative colitis as it may increase symptoms such as bloating, gas, and diarrhea. It is often recommended to limit fiber intake during flare-ups and focus on low-residue diets to reduce bowel activity.
D) "I should eat small, frequent meals throughout the day.": This is a recommended approach for managing ulcerative colitis. Small, frequent meals can help ensure adequate nutrient intake without overwhelming the digestive system, which can help manage symptoms and improve overall comfort.
Correct Answer is C
Explanation
A) Multiple clots in the client's urinary bag:
Multiple clots in the urinary bag can be expected after a transurethral resection of the prostate (TURP) as part of the normal postoperative bleeding. While clots can cause concern if they become excessive or obstructive, they are not as immediately critical as a persistent obstruction.
B) Client reports bladder spasms when repositioning in bed:
Bladder spasms are a common postoperative symptom following TURP and can be managed with antispasmodic medications and proper catheter care. Although uncomfortable, bladder spasms do not pose an immediate threat to the client’s health.
C) Obstruction in client's urinary catheter continues after manual irrigation:
A persistent obstruction in the urinary catheter after manual irrigation is a significant concern. This can indicate a severe blockage that might prevent urine from draining, leading to bladder distention, potential damage to the surgical site, and increased risk of infection. Immediate intervention is required to resolve the obstruction and ensure proper urinary drainage.
D) Client reports a pain rating of 3 on a 0 to 10 scale:
A pain rating of 3 on a 0 to 10 scale indicates mild pain, which is common in the postoperative period and can be managed with analgesics. While pain management is important, this level of pain does not constitute an urgent issue requiring immediate reporting to the provider.
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