A nurse is caring for a client experiencing fatigue secondary to anemia from chronic kidney disease (CKD). How should the nurse respond when the client asks about the cause of the anemia symptoms they are experiencing?

"You have a genetic tendency for the development of anemia."

"The increased metabolic waste products in your body depress the bone marrow and cause anemia."

"There is a decreased production by the kidneys of the hormone erythropoietin, which is the cause of your anemia."

"You are not eating enough iron-rich foods, which is causing anemia."

Answer and Explanation

The Correct Answer is C

A. "You have a genetic tendency for the development of anemia.”: Anemia in CKD is primarily due to impaired erythropoietin production, not genetics.

B. "The increased metabolic waste products in your body depress the bone marrow and cause anemia.”: While uremic toxins may have some marrow-suppressive effects, the main cause is lack of erythropoietin.

C. "There is a decreased production by the kidneys of the hormone erythropoietin which is the cause of your anemia.”: In CKD, damaged kidneys produce less erythropoietin, leading to reduced RBC production and anemia.

D. "You are not eating enough iron-rich foods, which is causing anemia.”: Although iron deficiency can contribute, this is not the primary cause in CKD-related anemia.

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Correct Answer is A

Explanation

A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds: High-pitched respiratory sounds (stridor) suggest impending airway obstruction, which is life-threatening and requires immediate intervention.

B. Client with facial burns and expectorating sooty secretions in no distress: At risk for inhalation injury but not in immediate respiratory distress.

C. Client with dry, black skin on both hands and a history of diabetes mellitus: Eschar and possible full-thickness burns are serious but not immediately life-threatening compared to airway compromise.

D. Client with moist blisters over the back and who reports pain as 10: Pain is expected and manageable; airway takes priority.

A. Encourage the client to cough and auscultate the lungs again. B. Document the change and continue to monitor the client's respiratory rate. C. Notify the health care provider and prepare for endotracheal intubation. D. Reposition the client in high-Fowler's position and reassess breath sounds.

Correct Answer is C

Explanation

A. Encourage the client to cough and auscultate the lungs again:
This delays necessary intervention and is not appropriate for suspected airway compromise.

B. Document the change and continue to monitor the client's respiratory rate:
Passive monitoring is not safe here given signs of impending respiratory failure.

C. Notify the health care provider and prepare for endotracheal intubation:
Facial burns and decreasing breath sounds suggest airway edema—immediate intubation is critical before complete airway obstruction.

D. Reposition the client in high-Fowler's position and reassess breath sounds:
While positioning helps breathing, it’s not sufficient or timely enough in a rapidly deteriorating airway.

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A nurse is caring for a client experiencing fatigue secondary to anemia from chronic kidney disease (CKD). How should the nurse respond when the client asks about the cause of the anemia symptoms they are experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is triaging multiple clients who arrived in the emergency department from a house fire. The nurse assesses that which client has the highest priority for care?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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