Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?
Blood pressure, heart rate, and temperature.
Leukocytes, neutrophils, and thyroxine.
Serum potassium, calcium, and phosphorus.
Erythrocytes, hemoglobin, and hematocrit.
The Correct Answer is C
Choice C reason: serum potassium, calcium, and phosphorus are electrolytes that can be affected by ESRD. ESRD is a condition in which the kidneys lose their ability to filter waste products and excess fluids from the blood. This can cause electrolyte imbalances that can lead to serious complications, such as cardiac arrhythmias, bone disorders, or metabolic acidosis. The nurse should closely monitor these electrolytes and report any abnormal values.
Choice A reason: blood pressure, heart rate, and temperature are vital signs that are not specific to ESRD. Vital signs can be influenced by many factors and may not reflect the severity of kidney damage. The nurse should monitor vital signs regularly, but not as closely as electrolytes.
Choice B reason: leukocytes, neutrophils, and thyroxine are not laboratory results that are directly related to ESRD. Leukocytes and neutrophils are types of white blood cells that are involved in immune response and inflammation. Thyroxine is a hormone that regulates metabolism and growth. These laboratory results may be altered by other conditions or medications, but not by ESRD.
Choice D reason: erythrocytes, hemoglobin, and hematocrit are laboratory results that measure the red blood cell count and oxygen-carrying capacity of the blood. These laboratory results may be decreased in ESRD due to anemia, which is a common complication of chronic kidney disease. However, anemia is not as life-threatening as electrolyte imbalances and can be treated with erythropoietin injections or iron supplements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Securing chest tube to the stretcher for transport is a good practice, but it is not the most important action. The chest tube should be secured to prevent accidental dislodgement or kinking, but it does not affect the function of the chest tube or the drainage system.
Choice B reason: Administering PRN pain medication prior to transport is a compassionate action, but it is not the most important action. The client may experience pain due to the chest tube, the intubation, or the underlying condition, but pain relief is not a priority over maintaining adequate ventilation and drainage.
Choice C reason: Marking the amount of chest drainage on the container is a useful action, but it is not the most important action. The amount of chest drainage should be recorded and reported to monitor the client's status and detect any complications, such as hemorrhage or infection, but it does not affect the immediate function of the chest tube or the drainage system.
Choice D reason: Keeping chest tube container below the site of insertion is the most important action for the nurse to take. The chest tube container should be kept below the level of the client's chest to maintain a gravity-dependent pressure gradient that allows air and fluid to drain from the pleural space. If the container is raised above the site of insertion, it can cause backflow of air or fluid into the pleural space, which can compromise ventilation and cause tension pneumothorax.
Correct Answer is A
Explanation
Choice A reason: Moderate amount of foul-smelling lochia. This is the most indicative finding of a postpartum infection, as it suggests that the client has endometritis, which is an inflammation of the uterine lining. Endometritis is a common cause of maternal morbidity and mortality, and requires prompt antibiotic treatment.
Choice B reason: Blood pressure of 122/74 mm Hg. This is a normal blood pressure for a postpartum client, and does not indicate an infection. The reference range for blood pressure is 90/60 to 140/90 mm Hg.
Choice C reason: Oral temperature of 100.2°F (37.9°C). This is a slightly elevated temperature for a postpartum client, but it does not necessarily indicate an infection. The reference range for oral temperature is 97.6 to 99.6°F (36.4 to 37.6°C). A mild fever may occur in the first 24 hours after delivery due to dehydration or hormonal changes.
Choice D reason: White blood cell count of 19,000/mm³ (19 x 10⁹/L). This is a high white blood cell count for a postpartum client, but it does not indicate an infection. The reference range for white blood cell count is 5,000 to 10,000/mm³ (5 to 10 x 10⁹/L). A leukocytosis may occur in the first few days after delivery due to stress or tissue injury.
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