A nurse is assessing a newly admitted client with a history of chronic heart failure who has new onset confusion after forgetting to take his medications for a few days. The client has peripheral edema, mild shortness of breath, and bilateral crackles in the lung bases. Which of the following assessments is the priority for the nurse?

Capillary refill and depth of peripheral edema

Abdominal sounds and obtain a BNP level

Neurological status and obtain electrolyte levels

Skin turgor and measure intake & output (I&O)

Answer and Explanation

The Correct Answer is C

A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Hypocalcemia: Hypocalcemia can cause signs such as muscle twitching, spasms, or tetany, which could be observed in the upper extremity and might be noted during a blood pressure measurement.
B. Hypokalemia: While hypokalemia can cause muscle weakness and cramping, it is less directly associated with specific upper extremity signs compared to hypocalcemia.
C. Hypophosphatemia: This generally affects energy levels and muscle function but is less commonly associated with immediate and visible upper extremity signs.
D. Hyponatremia: This primarily affects fluid balance and mental status, and is less likely to present with specific upper extremity findings during a blood pressure check.

A. Hypercholesterolemia B. Malnutrition C. Renal insufficiency D. Hypoparathyroidism

Correct Answer is B

Explanation

A. Hypercholesterolemia: This condition primarily affects cholesterol levels and is not directly associated with phosphorus imbalances. It does not typically cause hypophosphatemia.
B. Malnutrition: This is the correct choice. Malnutrition can lead to hypophosphatemia (low serum phosphorus levels) due to inadequate dietary intake of phosphorus and impaired absorption.
C. Renal insufficiency: Renal insufficiency generally causes hyperphosphatemia (high serum phosphorus levels) due to the kidneys' reduced ability to excrete phosphate, not hypophosphatemia.
D. Hypoparathyroidism: This condition is more commonly associated with hypocalcemia (low calcium levels) rather than hypophosphatemia. In some cases, hypoparathyroidism can cause elevated phosphorus levels, but not typically hypophosphatemia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The illustration reflects a client's upper extremity while the nurse obtains a manual blood pressure. Which electrolyte abnormality is the nurse most likely to see in the client's blood chemistry results?

Correct Answer is A

Explanation

A nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL. Which condition most likely caused this serum phosphorus level?

Correct Answer is B

Explanation

A nurse is preparing the skin of a client scheduled for cardiac surgery. What is the purpose of surgical skin cleaning preparation?

The nurse is educating a client on the use of oral ferrous sulfate. Which statement made by the client requires a need for further education?

A 28-year-old client is admitted to the hospital with severe bleeding from a fractured femur. Which intravenous fluid should the nurse anticipate will be ordered for volume replacement?

A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombosis?

A nurse is providing education in a community setting to several clients taking daily calcium supplements and encourages them to drink 2,500 mL of fluid daily. The nurse explains that this intervention is important to prevent which complication?

An unresponsive client was brought to the emergency room and had an arterial blood gas drawn. Ten minutes later, the laboratory calls with the following results: PaO2 74%, pH 7.22, PaCO2 85 mm Hg, and HCO3 23 mEq/L. The nurse interprets the results as indicating which imbalance?

The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?