While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Sodium intake with meals and snacks affects the blood pressure.

Hypotension leading to sudden shock can develop at any time.

Elevated blood pressure must be anticipated and identified quickly.

Blood pressure fluctuations mean that the condition has become chronic.

Answer and Explanation

The Correct Answer is C

Choice A reason: While sodium intake can affect blood pressure, this response does not address the importance of frequent blood pressure monitoring in the context of acute glomerulonephritis.

Choice B reason: Hypotension leading to sudden shock is not a common complication of acute glomerulonephritis; instead, hypertension is more likely due to fluid retention and kidney impairment.

Choice C reason: Elevated blood pressure is a significant concern in acute glomerulonephritis due to fluid retention and decreased kidney function. Early identification and management of hypertension are crucial to prevent complications such as seizures or heart failure.

Choice D reason: Blood pressure fluctuations do not necessarily indicate that the condition has become chronic. Frequent monitoring is necessary to manage acute symptoms and prevent complications.

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Correct Answer is C

Explanation

Choice A reason: Observing for jugular vein distention is important but not the immediate intervention.

Choice B reason: Monitoring oxygen saturation is necessary but secondary to preparing for pericardiocentesis.

Choice C reason: Pericardiocentesis is the definitive treatment for cardiac tamponade, and notifying the healthcare provider to prepare for this procedure is the most important intervention.

Choice D reason: Assessing for paradoxical blood pressure helps confirm cardiac tamponade but does not address the immediate need for treatment.

A. Obtain a 12-lead electrocardiogram daily. B. Evaluate glucose levels before and after meals. C. Monitor and document strict intake and output. D. Assess the serum potassium level every 4 hours.

Correct Answer is D

Explanation

Choice A reason: Obtaining a 12-lead electrocardiogram is important but not as frequent as monitoring potassium levels in this situation.

Choice B reason: Evaluating glucose levels is important but secondary to monitoring potassium levels.

Choice C reason: Monitoring and documenting intake and output are important but not as critical as frequent potassium level assessment.

Choice D reason: Frequent assessment of serum potassium levels is crucial due to the high initial potassium level and the use of insulin, which affects potassium levels.

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While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Correct Answer is D

Explanation

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