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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Calcium-based phosphate binders should not be taken with milk or calcium-rich foods, as this can lead to an excessive calcium load and increase the risk of hypercalcemia.
B. Incorrect. Calcium-based phosphate binders are most effective when taken with meals to bind to dietary phosphorus.
C. Incorrect. While vitamin D plays a role in calcium metabolism, its supplementation is not directly related to the use of calcium-based phosphate binders.
D. Correct. Constipation is a common side effect of calcium-based phosphate binders. Increasing fluid intake can help alleviate constipation and promote bowel regularity.
Questions
Correct Answer is C
Explanation
A. Incorrect. Severe anemia in chronic renal failure is characterized by low hemoglobin levels, not elevated levels.
B. Incorrect. Chronic renal failure can lead to decreased red blood cell production, resulting in a reduced red blood cell count.
C. Correct. Chronic renal failure often leads to decreased production of erythropoietin, a hormone that stimulates red blood cell production. This deficiency results in low hematocrit levels and severe anemia.
D. Incorrect. Chronic renal failure is not typically associated with elevated platelet counts; in fact, it can lead to platelet dysfunction and an increased risk of bleeding.
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