In a patient hospitalized with acute glomerulonephritis, nursing care included all of the following except?

BHU NO - 2015

Medical Surgical Nursing

Medium

Appeared in: BHU NO - 2015

Explanation

This option is the correct answer because it represents an inadequate frequency for monitoring a key indicator of fluid status.
In acute glomerulonephritis, fluid retention (edema) is a primary concern, and daily weight is the most sensitive measure to track changes in fluid balance.
Weighing a patient only twice a week would miss significant day-to-day fluid shifts, potentially delaying treatment for worsening fluid overload.
Standard nursing practice for patients with renal disease and fluid balance issues mandates daily weight measurement, at the same time, with the same scale, and in similar clothing.

Option A: This is a correct and necessary nursing action. Patients with acute glomerulonephritis are at high risk for developing hypertension, which is a major complication.
Option C: This is a correct and necessary nursing action. Meticulous monitoring of fluid intake and output is essential to assess kidney function and manage fluid balance.
Option D: This is a correct and necessary nursing action. Hypertension is a hallmark sign and a serious complication of acute glomerulonephritis. Frequent BP monitoring is crucial for early detection and management.

Clinical Relevance

Nursing practice connection: Use the key finding related to Nursing management and monitoring for a patient with acute glomerulonephritis to guide bedside assessment, documentation, and the next nursing action.
Daily weight is the most reliable indicator of fluid retention. A weight gain of 1 kg overnight corresponds to 1 liter of retained fluid.
Failure to monitor weight daily can lead to missed signs of worsening fluid overload, increasing the risk for severe complications like pulmonary edema and heart failure.
What if? If the patient developed sudden shortness of breath and crackles in the lungs, the nurse's priority would shift from routine monitoring to immediate intervention. This would include raising the head of the bed, administering oxygen, notifying the provider, and preparing to administer diuretics, as these are signs of acute pulmonary edema.

How to Approach the Question

First, identify that the question uses the word 'except', which means you are looking for the incorrect nursing action or the option that is not part of the standard care plan.
Review the pathophysiology of acute glomerulonephritis, focusing on its key features: inflammation, fluid retention (edema), and hypertension.
Evaluate each option based on these key features. Ask yourself, 'Is this action appropriate for managing fluid retention and hypertension?'
Option A & D (Vitals/BP q4h): This is appropriate for monitoring hypertension.
Option C (I&O q8h): This is appropriate for monitoring fluid balance.
Option B (Weight twice weekly): This seems infrequent for a condition characterized by rapid fluid shifts. Compare this to the standard of care, which is daily weights for renal patients.

Concept Tested & Keywords

Concept Tested: Nursing management and monitoring for a patient with acute glomerulonephritis.
Stem keywords: acute glomerulonephritis, hospitalized, nursing care
Lead-in keywords: except
Negative lead-in flag: This is a negative lead-in question, asking you to identify the incorrect nursing action.

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