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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Nausea and vomiting can lead to excessive loss of fluids and electrolytes, including potassium, from the body. Gastroenteritis is an inflammation of the gastrointestinal tract typically caused by viral or bacterial infections. It is commonly characterized by symptoms such as diarrhea, vomiting, abdominal pain, and fever. Antibiotics are not typically used to treat viral gastroenteritis and would not directly cause the electrolyte imbalance. Administration of IV Furosemide, a diuretic, would increase urine output but is not typically used to treat gastroenteritis. The fever itself may contribute to fluid loss but would not directly cause the electrolyte imbalance.
Correct Answer is C
Explanation
Pneumonia is an infection that causes inflammation in the lungs. Auscultation refers to listening to the sounds produced by the lungs using a stethoscope. Ronchi and fine crackles are abnormal lung sounds that can be heard during auscultation in individuals with pneumonia.
These sounds are associated with the presence of fluid or mucus in the lungs, which is characteristic of pneumonia.
While other symptoms such as a sore throat, tympany noted on chest percussion, and a slightly elevated temperature (37.8 degrees Celsius) can be present in various respiratory conditions, the auscultation findings of ronchi or fine crackles specifically suggest an underlying lung infection like pneumonia.
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