A nurse is caring for a client on a medical-surgical unit. Which intervention should the nurse prioritize?

Monitoring blood pressure trends after administering antihypertensive medication.

Administering prescribed Potassium Chloride 20 mEq PO STAT.

Reassessing the client for additional medication needs at 1300.

Educating the client about the importance of maintaining stable blood pressure levels.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Monitoring blood pressure trends ensures early detection of medication effectiveness, yet is secondary to addressing critical hypokalemia. Normal blood pressure is 120/80 mmHg; deviations warrant monitoring, but this is not the priority intervention.

Choice B rationale

Administering potassium chloride STAT addresses potential hypokalemia, which risks arrhythmias and muscle weakness. Normal potassium levels range between 3.5-5.0 mEq/L, highlighting urgency when potassium is below normal.

Choice C rationale

Reassessing additional medication needs at a set time ensures comprehensive care but does not address immediate life-threatening conditions like hypokalemia, which requires urgent correction to prevent cardiac dysfunction.

Choice D rationale

Educating about blood pressure maintenance is crucial for long-term management but does not address the immediate physiological imbalance or risk of arrhythmias due to electrolyte disturbance, making it a lower priority.

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Correct Answer is A

Explanation

Choice A rationale

Nausea is a direct clinical manifestation of enteral feeding intolerance, often resulting from delayed gastric emptying or improper feeding rate, leading to gastrointestinal distress and potential aspiration risks.

Choice B rationale

A urine output of 40 mL/hr, while indicative of oliguria and potential renal compromise, is not associated with gastrointestinal intolerance to enteral feedings, as these involve different organ systems.

Choice C rationale

Soft stools are not a reliable indicator of feeding intolerance. They can occur due to dietary composition changes but are not associated with pathologic conditions needing intervention.

Choice D rationale

Headache is a nonspecific symptom that does not relate directly to feeding intolerance. Other causes, such as dehydration or systemic factors, are more likely culprits for this presentation.

A. Stand-assist lift. B. Footboard. C. Slide board. D. Mechanical lift with a full body sling.

Correct Answer is A

Explanation

Choice A rationale

A stand-assist lift is suitable for clients with partial weight-bearing ability and upper body strength. It promotes independence by utilizing the client's own strength while ensuring safety during the transfer.

Choice B rationale

A footboard prevents foot drop in bedridden clients but is not designed for transferring clients between sitting and lying positions, offering no support for mobility or weight-bearing needs during transfers.

Choice C rationale

A slide board aids in lateral transfers for clients with minimal mobility or strength deficits. However, it is less effective for clients needing partial assistance in transferring from a sitting to a lying position.

Choice D rationale

A mechanical lift with a full body sling is used for non-weight-bearing clients requiring full support. It provides total assistance, making it unsuitable for clients with partial weight-bearing capacity.

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A nurse is caring for a client on a medical-surgical unit. Which intervention should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has been receiving intermittent enteral feedings. Which of the following findings should the nurse identify as an indication of intolerance to the feeding?

Correct Answer is A

Explanation

A nurse is preparing to transfer a client from a chair to the client’s bed. The client can bear partial weight and has upper body strength. Which of the following devices should the nurse use to transfer the client?

Correct Answer is A

Explanation

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