A nurse is caring for a client during a routine prenatal visit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

In this scenario, the client is most likely experiencing iron deficiency anemia, based on the diagnostic results that show low hemoglobin (10 mg/dL), low hematocrit (31%), and low serum ferritin (9 mcg/L), which are below the normal ranges for a pregnant individual.

The correct answers are:

Potential Condition:

a. Iron deficiency anemia

Actions to Take:

a. Administer iron supplements (to address the anemia and increase iron levels)
b. Teach the client about a diet rich in iron (to support iron supplementation and improve dietary intake of iron)

Parameters to Monitor:

a. Hemoglobin levels (to assess improvements in oxygen-carrying capacity and monitor for anemia)
b. Hematocrit levels (to monitor the volume of red blood cells and further assess anemia)

By addressing the low iron levels, administering supplements, and providing dietary guidance, the nurse can help correct the anemia. Monitoring hemoglobin and hematocrit will help track the client’s progress in overcoming the condition.

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Correct Answer is B

Explanation

Choice A reason: Hypophosphatemia

Hypophosphatemia, or low phosphate levels, is not typically associated with prerenal acute kidney injury (AKI). Prerenal AKI is primarily related to decreased blood flow to the kidneys, which does not directly affect phosphate levels. Hypophosphatemia is more commonly seen in conditions such as refeeding syndrome, chronic alcoholism, and certain endocrine disorders.

Choice B reason: Hyperkalemia

Hyperkalemia, or elevated potassium levels, is a common electrolyte imbalance in prerenal acute kidney injury (AKI). When kidney function is impaired, the kidneys are less able to excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac arrhythmias and requires prompt management. Hyperkalemia is often seen in various types of AKI, including prerenal, intrinsic, and postrenal causes.

Choice C reason: Hypercalcemia

Hypercalcemia, or high calcium levels, is not typically associated with prerenal AKI. In fact, AKI can sometimes lead to hypocalcemia (low calcium levels) due to impaired kidney function affecting calcium and phosphate metabolism. Hypercalcemia is more commonly associated with conditions such as hyperparathyroidism, malignancies, and certain medications.

Choice D reason: Hypernatremia

Hypernatremia, or high sodium levels, is also not a typical finding in prerenal AKI. Prerenal AKI is usually characterized by volume depletion, which can lead to hyponatremia (low sodium levels) due to the body’s attempt to retain water and maintain blood pressure. Hypernatremia is more commonly seen in conditions involving excessive water loss or inadequate water intake.

A. WBC count B. BUN C. Potassium

Correct Answer is A

Explanation

Choice A reason:

WBC count: An elevated white blood cell (WBC) count is a common indicator of infection. The body produces more white blood cells to fight off infections, making this a key marker for identifying infections in patients with pressure ulcers. Monitoring WBC count helps in assessing the presence and severity of an infection, guiding appropriate treatment.

Choice B reason:

BUN: Blood urea nitrogen (BUN) levels are used to assess kidney function and hydration status. Elevated BUN levels can indicate dehydration or kidney dysfunction but are not specific indicators of infection. While important for overall health assessment, BUN is not directly related to detecting infections in pressure ulcers.

Choice C reason:

Potassium: Potassium levels are crucial for maintaining normal cellular function, particularly in the heart and muscles. Abnormal potassium levels can indicate issues such as kidney dysfunction or electrolyte imbalances but do not specifically indicate infection. Monitoring potassium is important for overall health but not for diagnosing infections in pressure ulcers.

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The correct answers are:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

Correct Answer is B

Explanation

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

Correct Answer is A

Explanation

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