A nurse has just received the morning change of shift report for four clients. Which of the following clients has the highest priority need?
A client who has a serum potassium level of 5 mEq/L and is scheduled for dialysis in the afternoon.
A client who returned 1 hour ago from lithotripsy and is reporting nausea.
A client who had a total abdominal hysterectomy 2 days ago and is reporting a pain level of 3 on a scale of 0 to 10.
A client who has an indwelling urinary catheter and has a total urine output of 80 mL over the past 8 hours.
The Correct Answer is D
Choice A reason: While a serum potassium level of 5 mEq/L is at the higher end of the normal range, the client is scheduled for dialysis, which should address the issue.
Choice B reason: Nausea after lithotripsy is a concern, but it may not be as urgent as other conditions.
Choice C reason: A pain level of 3 is manageable and not the highest priority compared to other more acute needs.
Choice D reason: A urine output of 80 mL over 8 hours is significantly low and could indicate acute kidney injury or urinary retention, which requires immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Liquid iron supplements should not be taken undiluted as they can stain the teeth and may cause irritation to the digestive tract.
Choice B reason: Taking iron supplements with antacids is not recommended as antacids can interfere with the absorption of iron.
Choice C reason: Black stools can be a normal side effect of iron supplementation due to the unabsorbed iron; it does not necessarily indicate a need to contact a doctor unless there are other symptoms of concern.
Choice D reason: Increasing fiber intake can help prevent constipation, which is a common side effect of iron supplements.
Correct Answer is D
Explanation
Choice A reason: Obtaining vital signs is important, but it is not the first action to take when a client is experiencing dyspnea.
Choice B reason: Administering heparin is a treatment for pulmonary embolism, but the immediate need is to address the client's breathing difficulty.
Choice C reason: Encouraging the client to cough and deep breathe may be helpful, but it is not the first action to take for acute dyspnea.
Choice D reason: Placing the client in high Fowler’s position can help improve breathing and oxygenation, which is the immediate priority for a client experiencing dyspnea.
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