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 B
Explanation
A) Drink cold beverages to increase peristalsis: While hydration is important for overall health, drinking cold beverages specifically is not a well-supported method for increasing peristalsis. The key to avoiding constipation is adequate fluid intake, but it doesn't need to be cold.
B) Increase daily water intake: Increasing daily water intake is a fundamental and effective strategy to prevent constipation. Adequate hydration helps soften the stool, making it easier to pass and promoting regular bowel movements.
C) Take a daily laxative to soften stools: Relying on a daily laxative is not recommended for long-term management of constipation as it can lead to dependence and disrupt normal bowel function. Dietary and lifestyle changes are preferred for preventing constipation.
D) Eat a low-residue diet: A low-residue diet, which is low in fiber and roughage, is typically used for specific medical conditions and may contribute to constipation rather than prevent it. To avoid constipation, a high-fiber diet is usually recommended to promote healthy bowel movements.
Correct Answer is B
Explanation
A) Place the client on his right side if tube resistance occurs: Positioning the client on the right side can help facilitate gastric emptying, but it is not a primary action to ensure NG tube patency. If tube resistance occurs, the nurse should assess and address the resistance more directly.
B) Check the tube patency every 4 hr: Regularly checking the tube patency ensures that the NG tube remains open and functional, preventing blockages and ensuring continuous decompression or feeding as required.
C) Flush the tube with 50 mL of 0.9% sodium chloride irrigation every 8 hr: Flushing the tube helps maintain patency, but the amount and frequency may vary based on facility protocols. Flushing every 8 hours might not be frequent enough to prevent blockages.
D) Maintain the client in a supine position: Keeping the client in a supine position is not recommended for maintaining NG tube patency and may increase the risk of aspiration. A semi-Fowler's position is usually preferred to promote drainage and reduce aspiration risk.
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