What is the priority action the nurse will take for a 4-year old client admitted with minimal change nephrotic syndrome (MCNS) who has hypertension and facial edema?
Monitor the client's fluid volume and hydration status.
Teaching the client's parents about and preparing for a renal biopsy.
Consulting with a registered dietician about adequate intake.
Use only sterile techniques to prevent infections.
The Correct Answer is A
In a client with minimal change nephrotic syndrome (MCNS), the primary concern is the management of fluid volume and hydration status. MCNS is characterized by increased glomerular permeability, leading to excessive protein loss in the urine and subsequent hypoalbuminemia. This can result in fluid retention and edema formation, including facial edema.
Hypertension is a common complication in clients with MCNS, and it further contributes to fluid retention and potential complications. Therefore, closely monitoring the client's fluid volume and hydration status, including daily weights, intake and output measurements, and assessment of edema, is crucial to detect any changes and guide appropriate interventions.
While other actions, such as consulting with a registered dietitian about adequate intake or using sterile technique to prevent infections, may be important aspects of the client's care, they are not the priority in this situation. The immediate concern is managing the client's hypertension and fluid volume status to prevent complications associated with MCNS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Anaphylaxis is a severe and potentially life-threatening allergic reaction that can lead to a rapid drop in blood pressure, known as hypotension. This drop in blood pressure is a critical indicator of the severity of the reaction and the effectiveness of the treatment provided. The nurse needs to monitor the patient's blood pressure closely to ensure it stabilizes and returns to a safe range.
While oxygen saturation, heart rate, and orientation are also important parameters to assess, they are secondary to blood pressure in evaluating the effectiveness of treatment for anaphylaxis. Oxygen saturation can help determine the adequacy of oxygenation, heart rate can indicate the presence of tachycardia (which may be a sign of an ongoing reaction or hypoperfusion), and orientation can provide information about the patient's mental status and potential complications.
Correct Answer is B
Explanation
Dumping syndrome is a common complication after Gastric Bypass surgery, where food moves too quickly from the stomach to the small intestine. It occurs when the undigested contents of the stomach are "dumped" rapidly into the small intestine, leading to symptoms such as nausea, vomiting, abdominal cramps, diarrhea, lightheadedness, and sweating.
To manage dumping syndrome, it is important for the client to avoid foods and beverages that are high in sugar and carbohydrates. Consuming these types of foods can trigger rapid gastric emptying and exacerbate the symptoms. Instead, the client should focus on a well-balanced diet that includes lean proteins, healthy fats, and complex carbohydrates.
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