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A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain.
Exhibits

Select the top 4 client findings that requires immediate follow up.

Potassium 7.0 mEq/L (3.5 to 5 mEq/L)

WBC count 17,000/mm3 (Normal Finding: 5,000 to 10,000/mm3)

Crackles throughout lungs

Creatinine 3.0 mg/dL (0.5 to 1.3 mg/dL)

Abdomen rigid with decreased bowel sounds

Glucose 250 mg/dL

No dialysis for 24 hr

Hemoglobin 10 g/dL (12 to 18 g/dL) Nausea

Answer and Explanation

Correct Answer : A,B,C,H

A. Potassium 7.0 mEq/L (3.5 to 5 mEq/L): Elevated potassium levels (hyperkalemia) can cause life-threatening cardiac arrhythmias and are especially concerning in clients with chronic kidney disease who are at risk of renal complications. Immediate follow-up is crucial to prevent severe cardiac effects.

B. WBC count 17,000/mm³ (Normal Finding: 5,000 to 10,000/mm³): An elevated WBC count indicates an infection or inflammation, which is concerning given the client’s symptoms and temperature. This finding requires immediate follow-up to address potential infection.

C. Crackles throughout lungs: Crackles may indicate fluid overload or pulmonary edema, particularly in clients with chronic kidney disease. This could be a sign of worsening renal function or heart failure, which requires prompt attention.

H. No dialysis for 24 hr: Missing dialysis sessions in a client with stage IV chronic kidney disease can lead to dangerous fluid and electrolyte imbalances. This finding requires immediate action to prevent complications related to renal failure.

Explanation of Incorrect Options:

E. Creatinine 3.0 mg/dL (0.5 to 1.3 mg/dL): While elevated creatinine levels are concerning, the client’s history of chronic kidney disease means this level is expected to be higher. However, it is not as immediately critical as the other findings.

F. Abdomen rigid with decreased bowel sounds: This may suggest abdominal complications but is not as immediately critical as issues related to hyperkalemia or infection.

G. Glucose 250 mg/dL: Elevated glucose levels are concerning but less immediately critical compared to severe electrolyte imbalances and potential infections.

H. Hemoglobin 10 g/dL (12 to 18 g/dL): Anemia is a concern but is not as urgent as the immediate risks posed by elevated potassium, signs of infection, or missed dialysis.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Holding the client's arms and legs can cause injury and does not help in managing the seizure. The focus should be on protecting the client from harm.
B. Moving the client back to bed during a seizure can be dangerous and increase the risk of injury. It's best to manage the seizure where the client is.
C. Inserting a tongue blade or any object into the client's mouth can cause injury to the teeth or oral cavity and is not recommended during a seizure.
D. Placing the client on his side helps maintain an open airway and prevents aspiration, which is crucial during a seizure to ensure the client’s safety.

A. Notify the provider. B. Adjust the rate of the bladder irrigant. C. Irrigate the catheter. D. Check the tubing for kinks. E. Check the tubing for kinks.

Correct Answer is D

Explanation

A. Notifying the provider is important if initial interventions do not resolve the issue, but it is not the first action to take.
B. Adjusting the rate of the bladder irrigant may help, but first, it is essential to ensure that there is no mechanical obstruction in the tubing.
C. Irrigating the catheter can help clear any blockages, but the first step is to check for any kinks or obvious obstructions in the tubing.
D. Checking the tubing for kinks is the first action as it is a common and easily rectifiable cause of urinary catheter drainage issues. This should be done before other interventions.

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A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain. Exhibits Select the top 4 client findings that requires immediate follow up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain.
Exhibits

Select the top 4 client findings that requires immediate follow up.