A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. What intervention should the nurse include in this patient's plan of care?
Request a dietitian consult for selecting foods high in phosphorous.
Provide aluminum hydroxide antacids as prescribed.
Instruct the patient to avoid poultry, peanuts, and seeds.
Instruct the patient to avoid the intake of sodium phosphate.
The Correct Answer is A
Choice A rationale:
Hypophosphatemia is a condition characterized by low levels of phosphate in the blood, which can be caused by various factors, including malnutrition. In this case, the patient has a history of stomach ulcers, which might have contributed to poor nutrient absorption. The nurse should request a dietitian consult to ensure the patient receives an appropriate diet rich in phosphorus, which is essential for cellular function, bone health, and energy metabolism.
Choice B rationale:
Providing aluminum hydroxide antacids as prescribed is not the appropriate intervention for hypophosphatemia. Aluminum hydroxide antacids can bind to phosphate in the gastrointestinal tract, reducing its absorption and potentially worsening the patient's already low phosphate levels.
Choice C rationale:
Instructing the patient to avoid poultry, peanuts, and seeds is not suitable for this situation. These foods are good sources of phosphorus, and avoiding them would further deplete the patient's already low phosphate levels.
Choice D rationale:
Instructing the patient to avoid the intake of sodium phosphate is not necessary for hypophosphatemia. While sodium phosphate preparations are used as laxatives, there is no indication that the patient is taking them, and they are not relevant to the management of hypophosphatemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
The correct answer is choiceC. Monitor the injection site for redness,D. Use an infusion controller for the IV, andE. Monitor fluid intake and output.
Choice A rationale:
Adding the ordered dose to the IV hanging is incorrect because potassium chloride should never be added to an already hanging IV solution due to the risk of uneven distribution and potential overdose.
Choice B rationale:
Administering the dose IV push over 3 minutes is incorrect because potassium chloride should never be given by direct IV injection.It must always be diluted and administered slowly to prevent cardiac complications.
Choice C rationale:
Monitoring the injection site for redness is correct because potassium chloride can cause irritation and phlebitis at the injection site.
Choice D rationale:
Using an infusion controller for the IV is correct because it ensures the potassium chloride is administered at a controlled rate, reducing the risk of rapid infusion and potential cardiac issues.
Choice E rationale:
Monitoring fluid intake and output is correct because it helps assess the patient’s overall fluid balance and detect any signs of fluid overload or deficit, which is crucial when administering potassium.
Correct Answer is D
Explanation
Choice A rationale:
Increased urine ketones are not indicative of fluid volume deficit. Instead, they may suggest diabetic ketoacidosis or starvation ketosis.
Choice B rationale:
Decreased Hgb (hemoglobin) is not specific to fluid volume deficit and can be seen in various conditions such as anemia or bleeding.
Choice C rationale:
Decreased urine specific gravity is not consistent with fluid volume deficit, as it usually results in concentrated urine with increased specific gravity.
Choice D rationale:
An increased blood urea nitrogen (BUN) level is expected in fluid volume deficit due to reduced kidney perfusion and function. BUN is a marker of kidney function and is elevated when fluid volume is low.
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