Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD.?
Blood pressure, heart rate, and temperature.
Leukocytes, neutrophils, and thyroxine.
Serum potassium, calcium, and phosphorus.
Erythrocytes, hemoglobin, and hematocrit.
The Correct Answer is C
Choice A reason: Blood pressure, heart rate, and temperature are vital signs that should be monitored in any client, but they are not laboratory results. ESRD can cause hypertension and cardiovascular complications, so blood pressure and heart rate should be controlled with medications and lifestyle modifications. Temperature should be monitored for signs of infection or inflammation.
Choice B reason: Leukocytes, neutrophils, and thyroxine are not specific laboratory results for ESRD. Leukocytes and neutrophils are types of white blood cells that indicate immune system activity and infection. Thyroxine is a thyroid hormone that regulates metabolism and growth. ESRD can affect the immune system and the thyroid function, but these are not the primary indicators of renal function.
Choice D reason: Erythrocytes, hemoglobin, and hematocrit are laboratory results that measure red blood cell count, oxygen-carrying capacity, and blood volume. ESRD can cause anemia due to reduced production of erythropoietin, a hormone that stimulates red blood cell formation in the bone marrow. Anemia can cause fatigue, pallor, shortness of breath, and chest pain. However, these are not the most significant laboratory results for ESRD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.
Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.
Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.
Correct Answer is C
Explanation
Choice C is correct because observing the incision site of a client who was discharged home with a suprapubic catheter can help detect signs of infection, bleeding, or healing problems. The nurse should inspect the incision site for redness, swelling, drainage, or odor and report any abnormal findings.
Choice A is incorrect because measuring abdominal girth of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of urinary retention or obstruction. The nurse should monitor the urine output and color and report any changes.
Choice B is incorrect because assessing perineal area of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of infection or irritation. The nurse should instruct the client on how to keep the perineal area clean and dry and report any discomfort or discharge.
Choice D is incorrect because palpating flank area of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of urinary tract infection or kidney involvement. The nurse should ask the client about any pain or tenderness in the flank area and report any positive findings.
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