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","D","E"]
Explanation
Rationale:
A. Instruct the client to shower and wash her hair thoroughly: Decontamination by showering is essential to remove any anthrax spores from the skin and hair. Thorough washing reduces the risk of further spread and protects healthcare personnel and other patients.
B. Clean all surfaces touched by the client with vinegar and water: Vinegar and water are not effective against anthrax spores. Proper decontamination requires specific agents, such as a 0.5% hypochlorite (bleach) solution, under the guidance of hazardous materials protocols.
C. Place the client in a room with lead doors to contain airborne anthrax: Lead doors are used for radiation containment, not for biological threats like anthrax. Anthrax is not typically airborne unless aerosolized, so this intervention is unnecessary and ineffective.
D. Bag the clothes the client is wearing in plastic bags: Contaminated clothing can carry anthrax spores. Placing clothes in sealed plastic bags is a critical step in preventing environmental contamination and ensuring safe disposal.
E. Place the client on airborne precautions: While anthrax is not usually spread from person to person, airborne precautions are used if aerosol exposure is suspected, as in bioterrorism events. This helps contain spores until full decontamination is completed.
Correct Answer is D
Explanation
Rationale:
A. Encourage wearing a medical alert identification bracelet: While important for safety, especially in emergencies, it does not directly affect daily self-management or immediate health risks like hypoglycemia.
B. Explain the importance of counting carbohydrate intake: Carbohydrate counting is vital for glucose management but becomes more effective once the client understands how to handle acute complications like hypoglycemia.
C. Provide printed materials about the treatment of diabetes: Educational materials support learning, but the nurse must prioritize hands-on, actionable education—especially about emergencies like hypoglycemia.
D. Teach how to recognize and treat hypoglycemia: Hypoglycemia can occur quickly and lead to seizures, unconsciousness, or death if untreated. Teaching recognition and response is the most urgent priority for client safety.
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