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

Administer antibiotics.

Encourage increased fluid intake.

Encourage frequent ambulation.

Obtain weight weekly.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Administering antibiotics is a primary intervention for AGN when it is caused by a bacterial infection, such as post-streptococcal glomerulonephritis. Antibiotics help eliminate the infection and prevent further damage to the glomeruli.

Choice B Reason:
Encouraging increased fluid intake is not typically recommended for AGN, especially if the client has oliguria or edema, which are common in this condition. Fluid intake may need to be restricted to prevent fluid overload and worsening of hypertension.

Choice C Reason:
Frequent ambulation is not a priority intervention for AGN. While maintaining mobility is important, it does not directly address the renal inflammation or potential complications associated with AGN.

Choice D Reason:
Obtaining weight weekly is important for monitoring fluid status, but it is not the primary intervention. Daily weight measurements are more indicative of fluid retention or loss and are essential for closely monitoring the client's fluid balance.

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Correct Answer is C

Explanation

Choice A reason:
Keeping artificial nails trimmed is a recommended practice in healthcare settings to maintain effective hand hygiene. Long nails can harbor bacteria and make it difficult to clean hands thoroughly. However, the CDC does not provide specific guidelines on the length of artificial nails for healthcare workers.

Choice B reason:
When caring for a client with Clostridium difficile, it is recommended to wash hands with soap and water rather than using alcohol-based hand rubs. Alcohol-based hand rubs are not effective against C. difficile spores. Therefore, thorough handwashing with soap and water is necessary to remove spores.

Choice C reason:
Chlorhexidine is an antiseptic agent that provides broad-spectrum antimicrobial activity and is recommended for hand hygiene in certain situations, such as before invasive procedures or for clients who are immunosuppressed. It is effective against a wide range of bacteria, viruses, and fungi, making it a suitable choice for immunocompromised patients to reduce the risk of infection.

Choice D reason:
The use of alcohol-based hand rubs before administering eye drops is not specifically recommended. While hand hygiene is essential before any contact with a patient, there is no particular preference for alcohol-based hand rubs in this context. The primary concern is to ensure that hands are clean to prevent contamination of the eye drops or the patient's eyes.

A. Notify the client that they will receive a food tray in the recovery room. B. Remind the client they will return to their room after surgery. C. Inform the client that the recovery nurse will instruct them on how to manage postoperative pain. D. Provide instructions about how to cough and deep breathe effectively.

Correct Answer is D

Explanation

Choice A reason:
Notifying the client that they will receive a food tray in the recovery room is not typically a priority in preoperative education. Nutritional status post-surgery is important, but immediate postoperative care focuses on recovery from anesthesia and monitoring for complications.

Choice B reason:
Reminding the client that they will return to their room after surgery is part of routine information that may help orient the patient postoperatively. However, it is not a specific intervention that will aid in the recovery process or prevent complications.

Choice C reason:
Informing the client that the recovery nurse will instruct them on how to manage postoperative pain is important, but it is not the primary focus of preoperative education. Pain management is typically addressed both preoperatively and postoperatively.

Choice D reason:
Providing instructions on how to cough and deep breathe effectively is a critical component of preoperative education for clients undergoing abdominal surgery. Effective coughing and deep breathing exercises help prevent postoperative complications such as pneumonia and atelectasis by promoting lung expansion and secretion clearance.

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

Nursing Test Bank

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