In caring for a client with chronic kidney disease (CKD), the nurse notes that the client's serum phosphate level is elevated, with a converse decrease in serum calcium. Which nursing care goal is a priority, based on these laboratory findings?
Prevent injury.
Prevent infection.
Protect skin integrity.
Manage fluid volume.
The Correct Answer is A
Rationale:
A. Prevent injury: In CKD, high phosphate and low calcium levels contribute to bone demineralization, increasing fracture risk. Hypocalcemia can also cause muscle cramps and tetany, making fall prevention and safety a priority.
B. Prevent infection: While infection is a general concern in CKD, these specific lab findings do not indicate immunosuppression. The primary issue here relates to bone health and calcium-phosphate imbalance, not immune function.
C. Protect skin integrity: Skin care is important in CKD, especially with pruritus, but it is not the direct consequence of calcium-phosphate imbalance. The immediate risk related to these values is musculoskeletal, not dermatologic.
D. Manage fluid volume: Fluid volume control is essential in CKD but unrelated to phosphate-calcium shifts. These labs reflect mineral and bone metabolism disturbances, not volume overload or deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Decrease consumption of red meat and most seafood: These foods are high in purines, which are metabolized into uric acid. Reducing purine intake helps lower uric acid levels, minimizing the frequency and severity of gout flares.
B. Support joints in an extended position while resting: Keeping joints in an extended position may worsen discomfort and inflammation. During acute attacks, joints should be rested in a slightly flexed, supported position to relieve pressure.
C. Massage joints to relax muscles and decrease pain: Massage of an inflamed joint during a gout attack can increase pain and inflammation. The affected area is usually extremely sensitive and should be protected, not manipulated.
D. Replace dietary table salt with salt substitutes: Salt substitutes often contain potassium, which can interact with medications like NSAIDs or ACE inhibitors. This recommendation is unrelated to gout management.
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. Ask the client if someone brought her to the clinic: This may be useful in a general assessment but is not directly relevant to the client's urinary symptoms, bruising, or potential abuse concerns. It does not guide immediate care.
B. Review list of daily medications for aspirin or other anticoagulants: Ecchymoses may indicate increased bleeding risk, especially in older adults on aspirin or anticoagulants. Reviewing medications helps determine if bruising is medication-related or from trauma.
C. Question her if she previously or currently uses any illicit drugs: There’s no clinical indicator pointing toward drug use. This line of questioning may be inappropriate or unnecessary unless other findings support it.
D. Inquire if she is being emotionally or physically abused: Unexplained bruising, especially in older adults, can signal possible abuse. The nurse should screen for abuse sensitively and privately.
E. Determine number of sexual partners she has had recently: Given her report of sexual activity and urinary burning, assessing recent sexual history helps guide further STI screening and urinary symptom evaluation.
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