Which laboratory test results should the nurse monitor in a client who has end-stage renal disease (ESRD)?
Erythrocytes, hemoglobin, and hematocrit.
Serum potassium, calcium, and phosphorus.
Blood pressure, heart rate, and temperature.
Leukocytes, neutrophils, and thyroxine.
The Correct Answer is B
A. While monitoring erythrocytes, hemoglobin, and hematocrit is important in clients with ESRD due to the risk of anemia associated with kidney dysfunction, it is not the primary focus of monitoring for ESRD.
B. Clients with ESRD often experience electrolyte imbalances, including hyperkalemia (high potassium), hypocalcemia (low calcium), and hyperphosphatemia (high phosphorus). Monitoring these electrolyte levels is crucial to prevent complications such as cardiac arrhythmias, bone
disease, and soft tissue calcifications.
C. While blood pressure, heart rate, and temperature are essential vital signs to monitor in all clients, they are not specific laboratory tests for monitoring ESRD. However, blood pressure monitoring is particularly important in ESRD due to the increased risk of hypertension and its associated complications.
D. Monitoring leukocytes, neutrophils, and thyroxine levels is not typically a primary concern in clients with ESRD. Leukocyte and neutrophil levels may be monitored to assess for signs of infection, but they are not specific to ESRD. Thyroxine levels are typically monitored in clients with thyroid disorders, not ESRD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An increase in breath sounds may suggest improved airflow, but it does not necessarily indicate effective mobilization of secretions.
B. Absence of fine crackles indicates that there are no longer small airway secretions or fluid in the lungs, suggesting that the chest physiotherapy was effective in mobilizing secretions.
C. While the absence of coarse crackles is also a positive finding, fine crackles specifically indicate fluid or secretions in the small airways, making their absence a more direct indicator of the effectiveness of chest physiotherapy.
D. An increase in respiratory rate may indicate respiratory distress or worsening of the condition, rather than effectiveness of the chest physiotherapy in mobilizing secretions.
Correct Answer is ["A","B","E"]
Explanation
A. Neurological status: Assessing the neurological status is crucial in the primary survey to
determine the client's level of consciousness, pupil reactions, and response to stimuli. This helps in identifying any potential brain injury or neurological deficits resulting from the fall.
B. Circulation: Evaluating circulation involves assessing the client's heart rate, blood pressure, and peripheral perfusion. In this scenario, the client's heart rate and blood pressure are provided in the nurse's notes, indicating the need to assess circulation as part of the primary survey.
C. Current medications: While important for the overall assessment and care of the client, assessing current medications is typically part of the secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions.
D. Allergies: While allergies are essential information for the client's overall care, they are typically addressed during the secondary survey or during the history-taking process rather than as part of the primary survey.
E. Exposure: Assessing exposure involves ensuring the client is adequately covered and protected from environmental factors, especially in trauma situations where there may be significant blood loss or risk of hypothermia. This includes removing clothing to assess for additional injuries or bleeding.
F. Ventilation: While ventilation is crucial for assessing the client's respiratory status, including respiratory rate and effort, it is typically part of the primary survey rather than the primary survey itself. Assessing ventilation helps determine if the client is adequately breathing and oxygenating.
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