Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD.?
Serum potassium, calcium, and phosphorus
Erythrocytes, hemoglobin, and hematocrit
Leukocytes, neutrophils, and thyroxine
Blood pressure, heart rate, and temperature
The Correct Answer is A
Choice B reason: Erythrocytes, hemoglobin, and hematocrit are laboratory results that are not as critical as serum potassium, calcium, and phosphorus in a client who has end-stage renal disease (ESRD.. Erythrocytes are red blood cells that carry oxygen from the lungs to the tissues. Hemoglobin is a protein in erythrocytes that binds oxygen. Hematocrit is the percentage of blood volume that is occupied by erythrocytes. ESRD can cause anemia (low erythrocyte, hemoglobin, and hematocrit levels) due to reduced production of erythropoietin, a hormone that stimulates erythrocyte formation, by the kidneys. Anemia can cause fatigue, pallor, or shortness of breath.
Choice C reason: Leukocytes, neutrophils, and thyroxine are laboratory results that are not as relevant as serum potassium, calcium, and phosphorus in a client who has end-stage renal disease (ESRD.. Leukocytes are white blood cells that fight infection and inflammation. Neutrophils are a type of leukocyte that respond to bacterial infection. Thyroxine is a hormone that regulates metabolism and growth. ESRD can cause leukopenia (low leukocyte levels) and neutropenia (low neutrophil levels) due to impaired immune function and increased susceptibility to infection. ESRD can also cause hypothyroidism (low thyroxine levels) due to reduced clearance of thyroid hormones by the kidneys. Hypothyroidism can cause weight gain, cold intolerance, or depression.
Choice D reason: Blood pressure, heart rate, and temperature are not laboratory results, but vital signs that should be monitored in a client who has end-stage renal disease (ESRD.. Blood pressure is the force of blood against the walls of the arteries. Heart rate is the number of times the heart beats per minute. Temperature is the measure of body heat. ESRD can cause hypertension (high blood pressurE. due to fluid overload and activation of the renin-angiotensin-aldosterone system, a hormonal pathway that regulates blood pressure and fluid balance. Hypertension can cause headache, chest pain, or stroke. ESRD can also cause tachycardia (high heart ratE. due to anemia, fluid overload, or electrolyte imbalance. Tachycardia can cause palpitations, dizziness, or heart failure. ESRD can also cause fever (high temperaturE. due to infection or inflammation. Fever can cause chills, sweating, or delirium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["30"]
Explanation
First, we need to find the concentration of insulin in the IV solution, which is the ratio of insulin units to saline volume. To do this, we use the given information that the IV solution contains 100 units in 250 ml. So, we divide 100 by 250 and get 0.4 units/ml.
Next, we need to calculate the infusion rate in ml/hour for the ordered dose of 12 units/hour. To do this, we use the ratio of insulin units to saline volume, which is 0.4 units/ml. So, we set up a proportion as follows:
0.4/1=12/x
To solve for x, we cross-multiply and get 0.4 x = 12. Then, we divide both sides by 0.4 and get x = 30. So, the infusion rate is 30 ml/hour.
Therefore, the nurse should program the infusion pump to deliver 30 ml/hour..
Correct Answer is B
Explanation
Choice A reason: A 16-year-old client diagnosed with major depression who refuses to participate in group does not require the nurse's immediate attention. Depression is a mood disorder that causes persistent feelings of sadness, hopelessness, and loss of interest. Refusing to participate in group may indicate low motivation, social withdrawal, or poor self-esteem, which are common symptoms of depression. The nurse should respect the client's preference and offer alternative activities or individual therapy.
Choice B reason:This client requires immediate intervention because pacing can be a sign of agitation, restlessness, or escalating mania. Clients with bipolar disorder in a manic phase may exhibit increased energy, impulsivity, irritability, and even aggression. If not addressed promptly, this behavior could escalate to disruptive outbursts, impulsive actions, or even violence toward themselves or others. The nurse should intervene by using calm communication, redirection, and possibly medication if prescribed to help de-escalate the situation and ensure safety.
Choice Creason:This scenario involves peer conflict, which is important to address, but it does not necessarily indicate an immediate risk of harm. Clients with antisocial behavior often engage in conflict due to manipulative or confrontational tendencies, but being yelled at does not mean they are in immediate danger. The nurse should monitor the situation and intervene to prevent escalation, but other safety concerns take priority.
Choice D reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack does not require the nurse's immediate attention. Anorexia nervosa is an eating disorder that causes extreme restriction of food intake and fear of weight gain. Refusing to eat the evening snack may indicate distorted body image, dietary rules, or anxiety, which are common factors of anorexia nervosa. The nurse should encourage the client to eat and provide support and education.
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