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: Mark an outline of the 'olive-shaped' mass in the right epigastric area. This is not a priority action, as it does not address the immediate needs of the infant. The 'olive-shaped' mass is a sign of pyloric stenosis, but it does not affect the infant's hydration or nutrition.
Choice B: Instruct parents regarding care of the incisional area. This is an important action, but not a priority before surgery. The parents need to know how to care for the incisional area after surgery, but this can be done later.
Choice C: Monitor amount of intake and infant's response to feedings. This is a relevant action, but not a priority before surgery. The infant with pyloric stenosis may have vomiting, dehydration, and electrolyte imbalance due to gastric outlet obstruction. Monitoring intake and output can help assess the severity of these problems, but it does not correct them.
Choice D: Initiate a continuous infusion of IV fluids per prescription. This is the priority action before surgery, as it can prevent or treat dehydration and electrolyte imbalance in the infant. IV fluids can also help maintain blood volume and perfusion during surgery.
Correct Answer is B
Explanation
Choice A reason: When the client has ankle edema, it is important for the nurse to assess for other signs of fluid retention, such as weight gain, jugular venous distension, and crackles in the lungs. However, ankle edema alone is not a specific indicator of preeclampsia or eclampsia, which are conditions that can cause hyperreflexia or increased DTRs.
Choice C reason: During admission to labor and delivery, it is important for the nurse to assess various aspects of the client's health status, such as vital signs, fetal heart rate, contractions, cervical dilation, and pain level. However, assessing DTRs is not a routine part of labor and delivery assessment unless there are signs of preeclampsia or eclampsia.
Choice D reason: Within the first trimester of pregnancy, it is important for the nurse to assess for signs of pregnancy-related nausea and vomiting, bleeding, infection, and ectopic pregnancy. However, assessing DTRs is not a routine part of first trimester assessment unless there are signs of neurological disorders or spinal cord injury.
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