A nurse is caring for a 60-year-old female client on a medical-surgical unit.
Which action should the nurse take first?
Administer potassium supplements as prescribed.
Notify the provider of the laboratory results.
Encourage the client to eat potassium-rich foods.
Monitor the client for signs of hyperkalemia.
The Correct Answer is B
Choice A rationale: Administering potassium supplements may be appropriate, but the nurse must first notify the provider to confirm the treatment plan. Unilateral administration without provider input could lead to incorrect dosing.
Choice B rationale: Notifying the provider of the laboratory results is the priority to ensure prompt medical evaluation and intervention. The provider will determine the appropriate course of action based on the client's clinical condition and lab results.
Choice C rationale: Encouraging the client to eat potassium-rich foods is not the initial action. Diet changes take time to affect potassium levels, and immediate intervention is required to address the hypokalemia.
Choice D rationale: Monitoring for signs of hyperkalemia is inappropriate since the client has low potassium levels. The priority is to manage hypokalemia and prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Nasal flaring signals increased work of breathing due to airflow resistance or hypoxia, common in dyspnea associated with COPD. It indicates compensatory respiratory effort to maintain oxygenation under compromised airway conditions.
Choice B rationale
A respiratory rate of 16/min falls within the normal range (12 to 20 breaths/min) and doesn't indicate dyspnea. Dyspnea typically involves tachypnea or labored breathing as compensatory mechanisms in COPD.
Choice C rationale
Decreased depth of respirations isn't consistent with dyspnea in COPD, where accessory muscle use typically results in shallow, rapid breathing to maintain ventilation and compensate for airflow limitations.
Choice D rationale
A pulse oximetry reading of 95% is within normal limits (95 to 100%) and doesn't indicate hypoxia. COPD clients often have lower baseline oxygen saturation, and dyspnea is better assessed by clinical signs, not isolated saturation.
Correct Answer is B
Explanation
Choice A rationale
Older adults experience a decrease in subcutaneous tissue, particularly in extremities, due to age-related fat redistribution, making the skin thinner and more susceptible to injury.
Choice B rationale
Decrease in pigmentation is common in older adults as melanin production declines. This leads to lighter skin tone and the development of hypopigmented areas, often referred to as age spots.
Choice C rationale
Skin moisture levels typically decrease in older adults due to diminished sebaceous gland activity, leading to dryness rather than increased hydration or moisture retention.
Choice D rationale
Decreased elasticity is a hallmark of aging skin, caused by the breakdown of collagen and elastin fibers, resulting in sagging and an increased tendency for wrinkles.
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