A 4-year-old with acute glomerulonephritis is admitted to the hospital. The nurse is evaluating care and determines that goals have been met when which of the following is noted?
1. Electrolyte panel shows a sodium level of 149.
2. Lungs are clear on auscultation.
3. Edema is +3.
4. Blood pressure is 120/80.
2. Lungs are clear on auscultation.
Rationale:
Clear lungs are an indication that the child is no longer retaining fluid. A sodium level of 149 is abnormal. Edema assessed at +3 is still significant. The blood pressure is normal for an adult but too high for a 4-year-old.
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