A nurse is reinforcing teaching with a client who has acute glomerulonephritis with edema. Which of the following statements should the nurse make?
“You need to increase your daily fluid intake to 2 liters per day.”
“You will be prescribed an antifungal agent.”
“You should ambulate in the halls three times daily.”
“You should decrease your sodium intake.”
The Correct Answer is D
Choice A reason: Increasing daily fluid intake to 2 liters per day is not typically recommended for patients with acute glomerulonephritis and edema. In fact, fluid restriction is often necessary to manage edema and prevent fluid overload, which can exacerbate the condition.
Choice B reason: Prescribing an antifungal agent is not a standard treatment for acute glomerulonephritis unless there is a specific indication of a fungal infection, which is not commonly associated with this condition.
Choice C reason: While ambulation is generally good for overall health, recommending a specific frequency of ambulation in the halls three times daily without considering the patient’s overall condition and mobility is not appropriate. The level of activity should be tailored to the individual’s tolerance and clinical status.
Choice D reason: Decreasing sodium intake is a key recommendation for patients with acute glomerulonephritis, especially when edema is present. Sodium restriction helps to manage fluid retention and reduce swelling. It is also beneficial for controlling blood pressure, which can be elevated in this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Bleach is a widely recommended disinfectant for cleaning blood spills, especially in healthcare settings. The CDC suggests using a 1:10 dilution of household bleach with water to effectively kill pathogens present in blood spills. This solution should be applied to the affected area and allowed to air dry for at least 10 minutes to ensure proper disinfection.
Choice B Reason:
Chlorhexidine is an antiseptic agent more commonly used for skin disinfection before medical procedures rather than for cleaning environmental surfaces. While it has antimicrobial properties, it is not the preferred choice for cleaning blood spills as it may not be as effective as bleach in eliminating all potential pathogens.
Choice C Reason:
Isopropyl alcohol, while a good disinfectant for certain applications, is not the best option for cleaning blood spills. It does not have the same broad-spectrum killing power as bleach and may not be effective against all the pathogens that could be present in blood, particularly in a setting where a client has AIDS.
Choice D Reason:
Hydrogen peroxide is another common household disinfectant. However, it is generally less effective than bleach for cleaning blood spills. It may not kill all types of pathogens, especially in the concentrations typically available over the counter.
Correct Answer is C
Explanation
Choice A Reason:
Asking about allergies to medications is important for a complete medical history and could explain the current reaction. However, it is not the highest priority in this situation. The immediate concern should be the client's current symptoms and potential progression to a more severe reaction.
Choice B Reason:
Administering diphenhydramine, an antihistamine, is a common treatment for hives and itching due to an allergic reaction. While it is an appropriate action to take, it is not the highest priority. The nurse must first assess the severity of the reaction, particularly the client's airway and breathing.
Choice C Reason:
Difficulty breathing can indicate a severe allergic reaction, such as anaphylaxis, which is a life-threatening emergency. This statement is the highest priority because it directly addresses the client's airway, which can be compromised in severe allergic reactions.
Choice D Reason:
Taking the client's heart rate is part of the assessment and can provide important information about the client's hemodynamic status. However, it is not the highest priority. The nurse should first assess for any signs of respiratory distress, which would require immediate intervention.
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