A client with heart failure (HF) returns to the clinic two weeks after adjustments were made to the prescribed cardiac glycoside, diuretic, and potassium supplement. The client's lungs are clear, heart rate is 58 beats/minute, and serum potassium level is 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?

Reference Range:

Potassium (K+) [3.5 to 5.0mEq/L (3.5 to 5.0 mmol/L)]

Compare the weight with what it was at last visit.

Report serum potassium to healthcare provider.

Review the dietary history from the past week.

Check the pretibial areas and ankles for edema.

Answer and Explanation

The Correct Answer is B

A.   While weight monitoring is important for heart failure management, it's not the priority in this situation. The low potassium level is a more immediate concern.
B.   The serum potassium level of 2.9 mEq/L is significantly below the normal range and indicates hypokalemia. Hypokalemia can lead to serious cardiac arrhythmias, especially in patients taking cardiac glycosides. This is a critical finding that requires immediate attention from the healthcare provider.
C.   Dietary intake can contribute to potassium levels, but it's not the most urgent action at this time.
D.   Assessing for edema is important for monitoring heart failure status, but it's not the priority when there's a critical electrolyte imbalance.

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Correct Answer is B

Explanation

A. While this information might be helpful for general medication management, it is not directly related to the client's risk for osteoporosis.
B. The amount of calcium in the multivitamin is the most crucial follow-up information. For an older adult at risk for osteoporosis, ensuring adequate calcium intake is essential for bone health. Confirming the amount of calcium in the multivitamin helps ensure that the client is receiving enough of this critical nutrient to support bone density and reduce the risk of fractures.
C. This information is not relevant to the client's bone health or risk for osteoporosis.
D. While this information can influence the absorption of certain nutrients, it is not specifically related to calcium absorption or osteoporosis prevention.

A. Initiate a referral for ophthalmic evaluation as soon as possible. B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve C. Instruct the client to rest, and report to the emergency department if eye pain develops. D. Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.

Correct Answer is A

Explanation

A. The sudden onset of flashing lights and floaters can be a symptom of a detached retina, a serious eye condition that requires immediate medical attention.
B. This is incorrect. The client should not engage in any activities until the condition is evaluated by a healthcare professional.
C. While rest might seem appropriate, the client should seek immediate medical attention due to the potential seriousness of the symptoms.
D. Warm compresses are not indicated for this condition, and the client should seek immediate medical attention.

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Naxlex Comprehensive Predictor Exams

An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?

Correct Answer is B

Explanation

A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?

Correct Answer is A

Explanation

Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?

A client receiving thyroid replacement therapy following a thyroidectomy is seen in the dinic for a 6 weeks postoperative check-up. Which assessment is most important for the nurse to obtain?

Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

When learning to use an insulin pen, a client with diabetes dials 28 units of regular insulin instead of 24 units, the prescribed dose. Which action should the nurse take?

The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

Exhibits The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.