Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?

Manages activities of daily living independently.

Measures oral temperature daily.

Maintains blood pressure within normal limits.

Restricts fluid intake to 1 L/day.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Manages activities of daily living independently: Preserving functional independence is not a direct clinical outcome related to managing chronic pyelonephritis. The primary concern with this condition is preserving renal function and preventing long-term complications like hypertension.

B. Measures oral temperature daily: Monitoring temperature can help detect infections early, but chronic pyelonephritis may not always present with fever. It’s a short-term strategy and less critical than preventing progression to renal damage or cardiovascular complications.

C. Maintains blood pressure within normal limits: Chronic pyelonephritis can lead to kidney scarring, which often contributes to secondary hypertension. Controlling blood pressure is vital in slowing renal deterioration and preventing cardiovascular events, making it the most important long-term goal.

D. Restricts fluid intake to 1 L/day: Fluid restriction is not appropriate unless the client is in advanced kidney failure with fluid overload. Adequate hydration is usually encouraged to help flush bacteria from the urinary tract and support renal function.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A: This shows the IV insertion site on the hand. While important for checking infiltration or phlebitis, it does not affect flow rate or volume delivered, so it's not the priority in fluid overload.

B: This shows the IV drip chamber. This is the first place to assess because it allows the nurse to determine how fast the IV fluid is infusing. It provides a quick visual cue of the actual flow rate, which is essential in evaluating whether the infusion is too fast, the likely cause of the overload.

C: This is the IV tubing near the insertion site. Kinks or dislodgement can affect flow, but it’s not the most immediate concern when fluid overload is suspected.

D: Shows the roller clamp, this directly controls the flow rate in a gravity system, so it is the place to intervene when fluid overload is suspected. After assessing the flow rate in the drip chamber and confirming fast infusion, the nurse should adjust the flow rate at this part.

A. Assess for breath with a fruity odor. B. Titrate an insulin infusion to maintain a low serum glucose level. C. Monitor for elevated temperature and administer PRN antipyretics. D. Monitor serum electrolyte levels and report any abnormal values. E. Maintain large bore IV patency for aggressive fluid resuscitation.

Correct Answer is ["B","D","E"]

Explanation

Rationale:
A. Assess for breath with a fruity odor: This is more indicative of diabetic ketoacidosis (DKA), not HHS. HHS does not usually produce ketones or fruity-smelling breath, so it is not a priority assessment for this condition.

B. Titrate an insulin infusion to maintain a low serum glucose level: Maintaining glucose control through insulin infusion is critical in preventing HHS, as the syndrome is driven by severe hyperglycemia without ketosis.

C. Monitor for elevated temperature and administer PRN antipyretics: While fever management is important for burn care, it does not directly prevent HHS, which is primarily a result of fluid imbalance and hyperglycemia.

D. Monitor serum electrolyte levels and report any abnormal values: Electrolyte disturbances are common in HHS due to dehydration and osmotic diuresis. Prompt correction is essential to prevent complications.

E. Maintain large bore IV patency for aggressive fluid resuscitation: Massive fluid loss from burns and hyperglycemia requires aggressive IV fluid replacement to prevent dehydration and hemoconcentration, both of which contribute to HHS.

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Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving IV fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client's IV delivery system, where should the nurse assess first?

Correct Answer is B

Explanation

A client who has type 2 diabetes mellitus is admitted to the intensive care unit with third degree burns over 20% of the body. To decrease the client's risk of developing hyperosmolar hyperglycemic syndrome (HHS), which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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