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 A

Explanation

A. Administering an incorrect dose of insulin can lead to hypoglycemia, a serious complication. Discarding the incorrectly dialed dose ensures patient safety. Directly addresses the error and prevents potential harm.
B. This option is inefficient and increases the risk of error. It's unnecessary to use both a pen and a syringe for a single dose. Does not address the immediate issue of the incorrect dose.
C. Administering more insulin than prescribed is dangerous and can lead to hypoglycemia. Wasting the remainder doesn't address the core issue of the incorrect dose. Increases the risk of hypoglycemia.
D. Insulin pens are designed to be precise. Dialing down to the correct dose after an error can compromise the accuracy of the dose. Does not ensure accurate dosing.

A. Fatigue related to disease exacerbation. B. Pain related to joint inflammation C. Impaired physical mobility related to joint pain. D. Self-care deficit related to disease progression.

Correct Answer is B

Explanation

A. This is a valid nursing problem and directly related to the client's condition. However, while fatigue is a significant concern, it is often a symptom of other underlying issues.

B. This is the highest priority nursing problem. Pain is a primary symptom of acute RA exacerbation and significantly impacts the client's quality of life, mobility, and overall well-being. Addressing pain is crucial for immediate comfort and to facilitate other interventions.
C. This is also a valid nursing problem, directly linked to the client's symptoms. However, it is a consequence of the pain, not the primary issue. Addressing the pain will improve mobility.
D. This is a potential long-term concern but not the highest priority at this acute stage. The client's immediate needs related to pain and mobility are more pressing.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?

Correct Answer is B

Explanation

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?

The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?

A client is admitted with heart failure (HF) and left ventricular hypertrophy. Which intervention is most likely to avert development of cardiomegaly and improve myocardial contractility?

A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?

While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.