A client with intestinal obstruction has a nasogastric tube to low intermittent suction and is receiving an intravenous (IV) infusion of lactated Ringer's at 100 mL/hour.
Which finding is most important for the nurse to report to the healthcare provider? Reference Range: Potassium (3.5 to 5 mEq/L (3.5 to 5 mmol/L).

24-hour intake at the current infusion rate.

Serum potassium level of 3.1 mEq/L (3.1 mmol/L).

Gastric output of 900 mL in the last 24 hours.

Increased blood urea nitrogen (BUN).

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Reporting the 24-hour intake at the current infusion rate is not the most important finding to report to the healthcare provider in this case. It is essential to monitor intake and output, but a single report of the 24-hour intake is not as critical as other findings.

Choice B rationale:

Reporting a serum potassium level of 3.1 mEq/L (3.1 mmol/L) is the most important finding to report to the healthcare provider. The patient's potassium level is below the normal range, indicating hypokalemia. Hypokalemia can have serious cardiac and neuromuscular effects, including arrhythmias and muscle weakness. Prompt intervention, such as potassium supplementation or adjustment of IV fluids, is necessary to address this potentially life-threatening condition.

Choice C rationale:

Reporting a gastric output of 900 mL in the last 24 hours is significant and should be reported to the healthcare provider, but it is not as urgent as the low potassium level. Gastric output should be monitored to assess for signs of improvement or worsening, but hypokalemia takes precedence due to its immediate health risks.

Choice D rationale:

Reporting an increased blood urea nitrogen (BUN) is important for the overall assessment of the patient's renal function but is not the most critical finding in this scenario. The low potassium level is a more immediate concern and requires immediate attention.

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Correct Answer is A

Explanation

Choice A rationale:

Protamine sulfate is an antidote for heparin overdose and should be administered slowly intravenously to avoid rapid hemodynamic changes and potential adverse reactions.Administering it within 30 minutes ensures timely reversal of heparin’s anticoagulant effects.

Choice B rationale:

Administering protamine sulfate rapidly intramuscularly is incorrect because intramuscular administration is not recommended due to the risk of hematoma formation and slower absorption compared to intravenous administration.

Choice C rationale:

While slow intravenous administration is correct, the timing of 60 minutes is less effective compared to 30 minutes for reversing heparin’s effects promptly.

Choice D rationale:

Rapid intramuscular administration is incorrect for the same reasons as Choice B.Rapid administration can cause adverse reactions, and intramuscular administration is not the preferred route.

A. Take out dentures and place in a labeled cup. B. Gently close the eyes. C. Place a small pillow under the head. D. Apply a body shroud. E. Remove resuscitation equipment from the room.

Correct Answer is ["B","C","E"]

Explanation

The correct answers are B, C, and E: Gently close the eyes, Place a small pillow under the head, and Remove resuscitation equipment from the room.

Choice B rationale: Gently closing the eyes demonstrates respect for the deceased and can provide a more peaceful appearance for the family.

Choice C rationale: Placing a small pillow under the head is a way to provide comfort and dignity in death, as well as to create a more natural appearance.

Choice E rationale: Removing resuscitation equipment from the room allows for a more serene environment for the family to grieve and say their final goodbyes.

Choice A rationale: Dentures should be left in place, as they contribute to a more natural appearance of the deceased. The exception is if the family requests their removal or if it is the facility's policy to remove dentures.

Choice D rationale: Applying a body shroud is unnecessary when the family has requested to view the body before it is taken to the funeral home. Shrouds are typically used during transportation or if the family does not wish to view the body.

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Naxlex Comprehensive Predictor Exams

What are some important nursing considerations for this medication? *.

Correct Answer is A

Explanation

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

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