While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Sodium intake with meals and snacks affects the blood pressure.

Hypotension leading to sudden shock can develop at any time.

Elevated blood pressure must be anticipated and identified quickly.

Blood pressure fluctuations mean that the condition has become chronic.

Answer and Explanation

The Correct Answer is C

Choice A reason: While sodium intake can affect blood pressure, this response does not address the importance of frequent blood pressure monitoring in the context of acute glomerulonephritis.

Choice B reason: Hypotension leading to sudden shock is not a common complication of acute glomerulonephritis; instead, hypertension is more likely due to fluid retention and kidney impairment.

Choice C reason: Elevated blood pressure is a significant concern in acute glomerulonephritis due to fluid retention and decreased kidney function. Early identification and management of hypertension are crucial to prevent complications such as seizures or heart failure.

Choice D reason: Blood pressure fluctuations do not necessarily indicate that the condition has become chronic. Frequent monitoring is necessary to manage acute symptoms and prevent complications.

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Correct Answer is A

Explanation

Choice A reason: Completing the fall risk survey provides a comprehensive assessment of the client's fall risk, considering all factors.

Choice B reason: Informing the client that falls occur more often in the hospital does not complete the assessment.

Choice C reason: Recording a minimal risk based solely on the client's statement may not accurately reflect the true fall risk.

Choice D reason: Placing the client on high fall risk protocol based on age alone is not appropriate without a complete assessment.

A. Call for an assistant. B. Close the room door. C. Finish the procedure. D. Respond to the code.

Correct Answer is A

Explanation

Choice A reason: Calling for an assistant allows the nurse to ensure the client receiving tracheostomy care is safe and monitored while responding to the code blue, which is a priority emergency situation.

Choice B reason: Closing the room door does not address the need for assistance with the ongoing procedure and the emergency.

Choice C reason: Finishing the procedure may delay the nurse's response to the code blue, which requires immediate attention.

Choice D reason: Responding to the code without ensuring the current client is safe can lead to potential complications during tracheostomy care.

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While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

Correct Answer is A

Explanation

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Correct Answer is A

Explanation

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