A nurse is caring for a client who has anorexia related to AIDS.
Which of the following laboratory values should the nurse monitor to confirm the client's nutritional intake is adequate?

Albumin.

Lipase.

Creatinine clearance.

CD4-T-cell count.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Albumin is a protein synthesized by the liver, and its levels reflect long-term nutritional status. Hypoalbuminemia indicates inadequate protein intake or chronic illness. Normal serum albumin levels range from 3.5 to 5.0 g/dL. Monitoring albumin helps evaluate the effectiveness of nutritional interventions in clients with anorexia related to AIDS.

Choice B rationale

Lipase is an enzyme secreted by the pancreas involved in fat digestion. Elevated lipase levels indicate pancreatic dysfunction, not nutritional status, making it unsuitable for assessing nutritional intake adequacy.

Choice C rationale

Creatinine clearance assesses renal function and correlates with glomerular filtration rate. It is unrelated to nutritional status, making it irrelevant for determining nutritional adequacy in this case.

Choice D rationale

CD4-T-cell count evaluates immune status in AIDS clients. It reflects disease progression but does not provide direct information on nutritional intake or adequacy.

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Correct Answer is C

Explanation

Choice A rationale

A decrease in weight is common post-hemodialysis due to fluid removal. This is usually anticipated and does not require immediate reporting unless there are other associated symptoms or unusual weight patterns indicating fluid imbalance.

Choice B rationale

Vibration at the fistula site, known as a thrill, indicates proper functioning of the arteriovenous fistula. This finding is expected and does not necessitate urgent communication unless there are other complications.

Choice C rationale

Headache following hemodialysis may indicate fluid shifts, electrolyte imbalances, or other underlying problems. It should be reported to the provider for further evaluation and possible intervention to address these concerns.

Choice D rationale

Fatigue is a common post-hemodialysis symptom due to the physiological stress of the procedure. While expected, its severity should be evaluated in the context of other findings to determine if it needs attention.

A. Instruct the client to tilt their head back to facilitate swallowing. B. Schedule physical therapy directly before meals. C. Provide oral care before meals. D. Encourage the client to use a straw.

Correct Answer is C

Explanation

Choice A rationale

Instructing the client to tilt their head back increases the risk of aspiration by misaligning the airway and esophagus. Clients with dysphagia require strategies that minimize the risk of aspiration and promote safe swallowing, such as a neutral head position or chin tuck.

Choice B rationale

Scheduling physical therapy directly before meals is inappropriate as it may cause fatigue, reducing the client’s ability to eat safely. Proper scheduling ensures clients have sufficient energy to focus on eating, essential for minimizing aspiration risks in those with dysphagia.

Choice C rationale

Providing oral care before meals reduces the bacterial load in the oral cavity, lowering the risk of aspiration pneumonia if food or liquids are accidentally aspirated. Maintaining good oral hygiene is a key preventive measure for complications related to dysphagia.

Choice D rationale

Encouraging the use of a straw is contraindicated as it can increase the risk of aspiration. Using a straw can direct liquids forcefully to the throat, overwhelming the client’s ability to control swallowing, which is a safety concern for individuals with dysphagia.

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A nurse is caring for a client who has anorexia related to AIDS.Which of the following laboratory values should the nurse monitor to confirm the client's nutritional intake is adequate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is caring for a client who has anorexia related to AIDS.
Which of the following laboratory values should the nurse monitor to confirm the client's nutritional intake is adequate?