A client with chronic renal failure presents with swelling in the ankles and legs. What is the nurse's best action?
Apply compression stockings to the client's lower extremities.
Elevate the client's legs to reduce swelling.
Measure the client's blood pressure and pulse rate.
Assess the client's daily protein intake.
The Correct Answer is C
A. Incorrect. Applying compression stockings may help reduce swelling but does not address the underlying cause. Additionally, compression stockings should not be used if the client has arterial insufficiency.
B. Incorrect. Elevation may provide temporary relief from swelling, but it does not address the underlying cause of fluid retention
in chronic renal failure.
C. Correct. The nurse should measure the client's blood pressure and pulse rate to assess for fluid overload and possible hypertension, which can be associated with chronic renal failure.
D. Incorrect. Assessing the client's daily protein intake is not the priority when the client presents with swelling in the ankles and legs. Fluid retention is a more immediate concern that requires assessment and intervention.
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Related Questions
Correct Answer is B
Explanation
A. Incorrect. In chronic renal failure, the kidneys may have difficulty processing excess protein, so protein intake should be limited to reduce the workload on the kidneys.
B. Correct. Limiting fluid intake is crucial in managing chronic renal failure. The kidneys' reduced ability to filter waste products can lead to fluid retention and electrolyte imbalances, so restricting fluid intake helps prevent overload and complications.
C. Incorrect. In chronic renal failure, high-potassium foods should be limited to prevent hyperkalemia, a condition in which potassium levels in the blood become too high.
D. Incorrect. Foods high in phosphorus should be restricted in chronic renal failure because the kidneys may have difficulty excreting excess phosphorus, leading to hyperphosphatemia, which can contribute to bone and mineral disorders.
Correct Answer is B
Explanation
A. Incorrect. Excess production of calcium in the body is not a typical cause of bone pain in chronic renal failure.
B. Correct. Chronic renal failure can lead to impaired phosphorus excretion, resulting in elevated levels of phosphorus in the blood. High phosphorus levels can lead to bone demineralization, weakening the bones and causing bone pain.
C. Incorrect. While some medications used in the management of chronic renal failure may have side effects, frequent bone pain is not commonly associated with these medications.
D. Incorrect. Kidney dysfunction in chronic renal failure does not typically lead to low levels of calcium in the bones. Instead, it can lead to abnormalities in phosphorus levels, which affect bone health.
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