The nurse is assessing a client who is admitted to the renal unit with suspected decreased renal perfusion. The nurse should plan to carefully monitor which parameter?
Reference Range: Urine white blood cells (WBC) [0 to 4 WBC/low powered field (lpf)]

Blood pressure of 100/80 mm Hg.

Abdominal pulse noted on inspection.

Urinalysis with 1 to 4 WBC/lpf.

Urinary output of 30 mL/hour.

Answer and Explanation

The Correct Answer is D

Choice A reason: A blood pressure of 100/80 mm Hg is low but not specific for renal perfusion without context. Urinary output directly reflects kidney function, with 30 mL/hour indicating possible oliguria. Monitoring output is critical, per renal assessment and acute kidney injury management protocols in nursing care.

Choice B reason: Abdominal pulse on inspection is unrelated to renal perfusion, typically indicating vascular issues like aneurysms. Urinary output is a direct indicator of kidney function, with 30 mL/hour suggesting reduced perfusion. This is irrelevant, per renal assessment and diagnostic standards in nephrology nursing.

Choice C reason: Urinalysis with 1 to 4 WBC/lpf is within normal range and suggests no infection. Urinary output of 30 mL/hour is concerning for decreased renal perfusion, requiring close monitoring. WBCs are less critical, per renal function and acute kidney injury assessment guidelines in nursing.

Choice D reason: Urinary output of 30 mL/hour indicates possible oliguria, a key sign of decreased renal perfusion. Monitoring this parameter assesses kidney function, guiding interventions to prevent acute kidney injury. It is the most direct indicator, per renal perfusion and critical care protocols in nephrology nursing practice.

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Correct Answer is C

Explanation

Choice A reason: Avoiding heavy lifting is correct, as it increases intraocular pressure (IOP) in glaucoma, damaging the optic nerve. This statement shows understanding, as limiting activities that elevate IOP protects retinal ganglion cells, reducing progression risk, aligning with proper glaucoma management strategies.

Choice B reason: Glaucoma can cause vision loss if untreated, as elevated IOP damages optic nerve fibers, leading to irreversible blindness. This statement reflects accurate understanding of the disease’s progressive nature, emphasizing the need for management to preserve vision, requiring no further teaching.

Choice C reason: Eye drops (e.g., timolol) reduce IOP but do not cure glaucoma or restore vision, as optic nerve damage is irreversible. This statement indicates misunderstanding, as glaucoma is chronic, requiring lifelong management to slow progression, necessitating further teaching to correct this misconception.

Choice D reason: Regular eye exams monitor IOP and optic nerve health in glaucoma, preventing progression. This statement shows understanding, as consistent follow-up detects changes in retinal nerve fiber layer thickness, ensuring timely adjustments in therapy, aligning with effective disease management.

A. Start the collection time now and stop the collection the next day at the same time. B. Provide catheter care at the urinary site to prevent contamination of the specimens. C. Clamp the catheter to control urine flow during the collection period. D. Label the collection container with the client’s name and start time.

Correct Answer is A

Explanation

Choice A reason: Starting the collection time after emptying the bag ensures an accurate 24-hour urine sample, critical for diagnostic tests like creatinine clearance. This defines the collection period, per laboratory and diagnostic specimen collection protocols in nursing practice.

Choice B reason: Catheter care prevents infection but is not the most critical step for initiating a 24-hour collection. Starting the collection time ensures accurate timing, essential for valid results, per urinary specimen collection and infection control standards in nursing.

Choice C reason: Clamping the catheter is inappropriate, as it disrupts continuous urine flow, skewing the 24-hour collection. Starting the collection time ensures accurate sampling, critical for diagnostic accuracy, per urinary catheter management and laboratory protocols in nursing practice.

Choice D reason: Labeling the container is important but secondary to starting the collection time, which defines the 24-hour period for accurate results. Timing ensures valid diagnostic data, per specimen collection and laboratory standards in nursing practice for urine collections.

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The nurse is assessing a client who is admitted to the renal unit with suspected decreased renal perfusion. The nurse should plan to carefully monitor which parameter? Reference Range: Urine white blood cells (WBC) [0 to 4 WBC/low powered field (lpf)]

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Correct Answer is A

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The nurse is assessing a client who is admitted to the renal unit with suspected decreased renal perfusion. The nurse should plan to carefully monitor which parameter?
Reference Range: Urine white blood cells (WBC) [0 to 4 WBC/low powered field (lpf)]