A home health client with end-stage renal disease (ESRD) has a nursing diagnosis of powerlessness related to life-altering disease. Which priority nursing intervention should the nurse include in the plan of care?
Select one:

Include the client during development of the plan of care.

Write out a detailed schedule of upcoming health care provider's appointments.

Ensure restricted protein intake to prevent nitrogenous product accumulation.

Increase daily intake of sodium.

Answer and Explanation

The Correct Answer is A

A. This is the priority intervention to address powerlessness. Involving the client in planning promotes autonomy, empowerment, and a sense of control over their own care — which directly counters feelings of powerlessness associated with chronic, life-altering illness like ESRD.

B. While helpful for organization and adherence, this is not priority in addressing emotional or psychological issues like powerlessness. It is more of a supportive or logistical intervention.

C. This is a clinical management issue related to renal diet, not a direct intervention for powerlessness.

D. clients with ESRD typically require sodium restriction, not an increase, to manage fluid retention and hypertension.

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Correct Answer is D

Explanation

A. Edema is more commonly due to fluid overload and impaired renal excretion of sodium and water, not primarily caused by low potassium levels.
B. Seizures are more typically linked to electrolyte imbalances such as low sodium or low calcium, not potassium.
C. Respiratory depression is more commonly associated with opioid use, high magnesium, or neuromuscular suppression, not hypokalemia.
D. Critically low potassium (hypokalemia) impairs normal cardiac conduction and increases the risk for life-threatening arrhythmias, making this the most dangerous and priority complication to monitor for.

A. Slight bruising at the IV insertion site B. Blood pressure of 110/72 C. Metformin on the home medication list D. Urine output of 30/ml hr

Correct Answer is C

Explanation

A. Mild bruising is a common and usually benign finding at an IV site and not a contraindication to contrast dye administration.

B. This is within normal limits and not concerning before a diagnostic test with contrast.

C. Metformin must be used with caution when a patient is receiving iodinated contrast dye due to the risk of lactic acidosis, especially if the patient develops contrast-induced nephropathy. Typically, metformin is held before and for 48 hours after the procedure until renal function is confirmed to be stable.

D. This is the minimum acceptable urine output and does not by itself contraindicate contrast dye use, though renal function should still be monitored.

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A home health client with end-stage renal disease (ESRD) has a nursing diagnosis of powerlessness related to life-altering disease. Which priority nursing intervention should the nurse include in the plan of care? Select one:

Nursing Test Bank

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Correct Answer is D

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Correct Answer is C

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A home health client with end-stage renal disease (ESRD) has a nursing diagnosis of powerlessness related to life-altering disease. Which priority nursing intervention should the nurse include in the plan of care?
Select one: