When conducting an admission assessment, the nurse notes that an adult female client has developed two new allergies since her last admission. The client describes herself as lactose intolerant and states that she is unable to eat eggs. Which intervention(s) should the nurse implement? (Select all that apply.)

Apply an allergy identification wrist band.

Instruct the client to avoid medication containing milk and eggs.

Enter allergy information in the client's electronic medical record.

Ensure the client's selections from her dietary menu.

Notify the dietary department of the client's egg intolerance.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A: Applying an allergy identification wrist band is an intervention that the nurse should implement, as this can alert other health care providers of the client's allergies and prevent adverse reactions. Therefore, this is a correct choice.

Choice B: Instructing the client to avoid medication containing milk and eggs is not an intervention that the nurse should implement, as this is not a common or relevant source of allergens for this client. This is an incorrect choice.

Choice C: Entering allergy information in the client's electronic medical record is an intervention that the nurse should implement, as this can ensure accurate and updated documentation of the client's allergies and facilitate communication among health care providers. Therefore, this is another correct choice.

Choice D: Ensuring the client's selections from her dietary menu is an intervention that the nurse should implement, as this can help avoid foods that may trigger allergic reactions or intolerance for this client. Therefore, this is another correct choice.

Choice E: Notifying the dietary department of the client's egg intolerance is an intervention that the nurse should implement, as this can help modify or substitute foods that contain eggs for this client. Therefore, this is another correct choice.

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Free Nursing Study Resources

Correct Answer is ["B","C","E","F"]

Explanation

Choice A reason: Alcohol consumption will not produce vascular changes is incorrect information. Alcohol consumption can increase blood pressure by causing vasoconstriction, fluid retention, and interference with antihypertensive medications. The nurse should advise the client to limit alcohol intake to no more than one drink per day for women and two drinks per day for men.

Choice B reason: Weight management is promoted by taking daily walks for thirty minutes is correct information. Weight management can lower blood pressure by reducing body fat, improving blood circulation, and enhancing insulin sensitivity. The nurse should advise the client to maintain a healthy weight and engage in moderate physical activity for at least 150 minutes per week.

Choice C reason: Salt substitutes can help with maintaining a healthy diet is correct information. Salt substitutes can reduce sodium intake by replacing sodium chloride with potassium chloride or other minerals. The nurse should advise the client to use salt substitutes sparingly and consult with their healthcare provider before using them if they have kidney disease or take certain medications that affect potassium levels.

Choice D reason: Blood pressure readings should be taken at noontime is incorrect information. Blood pressure readings should be taken at different times of the day, preferably in the morning and evening, to monitor fluctuations and trends. The nurse should advise the client to use a home blood pressure monitor that is accurate and calibrated and follow proper techniques for measuring blood pressure.

Choice E reason: Sodium intake can be regulated by limiting canned foods in the diet is correct information. Sodium intake can increase blood pressure by causing fluid retention and increasing vascular resistance. The nurse should advise the client to limit sodium intake to no more than 2300 mg per day and avoid processed foods that are high in sodium, such as canned foods, soups, sauces, and snacks.

Choice F reason: Uncontrolled hypertension can lead to renal damage is correct information. Uncontrolled hypertension can damage the blood vessels in the kidneys, leading to reduced kidney function and chronic kidney disease. The nurse should advise the client to follow their prescribed treatment plan and monitor their blood pressure regularly.

A. Blood pressure, heart rate, and temperature. B. Leukocytes, neutrophils, and thyroxine. C. Serum potassium, calcium, and phosphorus. D. Erythrocytes, hemoglobin, and hematocrit.

Correct Answer is C

Explanation

Choice C is correct because serum potassium, calcium, and phosphorus are electrolytes that can be affected by ESRD. ESRD is a condition in which the kidneys lose their ability to filter waste products and excess fluids from the blood. This can cause electrolyte imbalances that can lead to serious complications, such as cardiac arrhythmias, bone disorders, or metabolic acidosis. The nurse should closely monitor these electrolytes and report any abnormal values.

Choice A is incorrect because blood pressure, heart rate, and temperature are vital signs that are not specific to ESRD. Vital signs can be influenced by many factors and may not reflect the severity of kidney damage. The nurse should monitor vital signs regularly, but not as closely as electrolytes.

Choice B is incorrect because leukocytes, neutrophils, and thyroxine are not laboratory results that are directly related to ESRD. Leukocytes and neutrophils are types of white blood cells that are involved in immune response and inflammation. Thyroxine is a hormone that regulates metabolism and growth. These laboratory results may be altered by other conditions or medications, but not by ESRD.

Choice D is incorrect because erythrocytes, hemoglobin, and hematocrit are laboratory results that measure the red blood cell count and oxygen-carrying capacity of the blood. These laboratory results may be decreased in ESRD due to anemia, which is a common complication of chronic kidney disease. However, anemia is not as life-threatening as electrolyte imbalances and can be treated with erythropoietin injections or iron supplements.

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Naxlex Comprehensive Predictor Exams

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)

Correct Answer is ["B","C","E","F"]

Explanation

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD.?

Correct Answer is C

Explanation

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