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A nurse has received change-of-shift report on four clients.
Which of the following clients should the nurse plan to see first?

A client who is short of breath.

A client who received pain medication 30 min ago.

A client who is to be discharged at 11:00.

A client who is ambulatory and going for an x-ray at 10:00.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

A client who is short of breath is experiencing a life-threatening situation and should be seen first.

Choice B rationale:

A client who received pain medication 30 min ago is likely to be comfortable and can be seen later.

Choice C rationale:

A client who is to be discharged at 11:00 can be seen closer to the discharge time.

Choice D rationale:

A client who is ambulatory and going for an x-ray at 10:00 can be seen after the x-ray.

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Correct Answer is B

Explanation

Choice A rationale:

Hyperventilation is a compensatory mechanism for metabolic acidosis, not a cause. It helps to eliminate carbon dioxide, a weak acid, to balance the pH.

Choice B rationale:

Diarrhea causes loss of bicarbonate, a base, from the body. This can lead to metabolic acidosis as there is an excess of acids.

Choice C rationale:

Salicylate intoxication can cause both respiratory alkalosis and metabolic acidosis. However, it is not the most common cause of metabolic acidosis.

Choice D rationale:

Vomiting leads to loss of gastric acid, a strong acid. This usually results in metabolic alkalosis, not acidosis.

A. Repeat the potassium level. B. Withhold the medication. C. Monitor for paresthesia. D. Administer a hypertonic solution.

Correct Answer is B

Explanation

Choice A rationale:

Repeating the potassium level is not the first action to take. The nurse already has a recent lab value.

Choice B rationale:

The nurse should withhold the medication. The normal range for potassium is 3.5-5.0 mEq/L. A level of 5.5 mEq/L is high, so giving more potassium could lead to hyperkalemia.

Choice C rationale:

Monitoring for paresthesia is important in hyperkalemia, but it is not the first action. The nurse should first prevent further increase in potassium levels.

Choice D rationale:

Administering a hypertonic solution is not relevant in this situation. It does not directly address the high potassium level.

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A nurse has received change-of-shift report on four clients.Which of the following clients should the nurse plan to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has metabolic acidosis.The nurse should realize that which of the following findings contributes to the development of metabolic acidosis?

Correct Answer is B

Explanation

A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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A nurse has received change-of-shift report on four clients.
Which of the following clients should the nurse plan to see first?