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 C

Explanation

Choice A rationale

A carotid bruit signifies turbulent blood flow in the carotid artery, often due to arterial narrowing. It does not directly indicate ineffective cardiac contractions or relate to cardiac output efficiency.

Choice B rationale

A heart murmur indicates abnormal blood flow across heart valves, which can result from structural defects or valve dysfunction. It does not directly measure or confirm ineffective cardiac contractions.

Choice C rationale

A pulse deficit occurs when heartbeats are not effectively generating palpable pulses, indicating weak cardiac contractions or poor perfusion. This suggests the heart is not pumping effectively.

Choice D rationale

A bounding radial pulse indicates strong cardiac contractions with increased stroke volume or sympathetic stimulation. It does not signify ineffective cardiac contractions but rather heightened cardiovascular activity.

A. Attach a probe carefully to the client’s finger. B. Apply a sensor pad to the client’s forehead. C. Secure a probe to one of the client’s toes. D. Obtain a pulse oximetry reading using an alternative site.

Correct Answer is B

Explanation

Choice A rationale

Peripheral edema may impede accurate readings due to compromised capillary blood flow in fingers. Thickened toenails may further reduce sensor reliability, leading to errors in oxygen saturation measurement.

Choice B rationale

The forehead is ideal for pulse oximetry in patients with peripheral edema. It provides a reliable alternative site with consistent capillary blood flow and is unaffected by thickened nails or peripheral circulation issues.

Choice C rationale

Peripheral edema affects capillary blood flow in toes, and thickened toenails obstruct sensor attachment, leading to unreliable and inaccurate oxygen saturation readings for clinical assessment.

Choice D rationale

While alternative sites might be useful, the forehead offers a proven, optimal placement for reliable oxygen saturation readings in cases of peripheral edema and other extremity-related complications.

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

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Naxlex Comprehensive Predictor Exams

A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?

Correct Answer is C

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A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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