A nurse is reviewing the client's serum electrolyte levels which are as follows:

Sodium: 138 mEq/L (138 mmol/L)

Potassium 3.2 mEq/L (3.2 mmol/L)

Calcium 100 mg/dL (2.5 mmol/L)

Magnesium 20 mEq/L (1.0 mmol/L)

Chloride 100 mEq/L (100 mmol/L)

Phosphate 4.5 mg/dL (26 mEq/L)

Based on these levels, the nurse would identify which imbalance?

hypermagnesemia

hyponatremia

hypokalemia

hypercalcemia

Answer and Explanation

The Correct Answer is C

A. hypermagnesemia: The magnesium level is 1.0 mmol/L (approximately 2.0 mEq/L), which falls within the normal range (1.5–2.5 mEq/L), so this is not consistent with hypermagnesemia.

B. hyponatremia: The sodium level is 138 mEq/L, which is within the normal range of 135–145 mEq/L, and does not indicate a sodium imbalance.

C. hypokalemia: The potassium level is 3.2 mEq/L, which is below the normal range of 3.5–5.0 mEq/L, indicating hypokalemia. This can cause muscle weakness, cardiac arrhythmias, and other complications.

D. hypercalcemia: The calcium level is 100 mg/dL (or 2.5 mmol/L), which is within the normal range of 8.5–10.5 mg/dL (or 2.1–2.6 mmol/L), so hypercalcemia is not present.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Evaluation: Evaluation involves determining whether established goals have been met after nursing interventions, which occurs later in the process than discharge planning. It is focused on measuring outcomes rather than preparing them.

B. Analysis: Analysis (also called diagnosis) is the step where the nurse interprets assessment data to identify client problems, but it does not involve coordination of discharge services or interprofessional collaboration.

C. Planning: Planning includes setting goals, determining priorities, and coordinating with other health care professionals to develop strategies for discharge and continued care. This ensures the client’s needs are met after leaving the facility.

D. Assessment: Assessment involves collecting data about the client’s health status, which is foundational but does not include the step of coordinating a discharge plan or working with interdisciplinary teams.

A. Complete the task quickly, then obtain PPE. B. Stop and obtain appropriate PPE. C. Ask a colleague to perform the task. D. Leave PPE in the room for the next person.

Correct Answer is B

Explanation

A. Complete the task quickly, then obtain PPE: This action risks exposure to infectious agents and violates infection control protocols. Speed does not justify unsafe practice.

B. Stop and obtain appropriate PPE: The nurse should immediately stop the task and put on the necessary PPE to protect themselves and prevent the spread of infection before proceeding.

C. Ask a colleague to perform the task: Transferring the task does not address the nurse’s responsibility to maintain safety and infection control. The nurse must follow proper protocols personally.

D. Leave PPE in the room for the next person: PPE should be donned and doffed properly for each use and not left unattended or assumed to be for others’ use, which can lead to contamination or improper use.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of nursing process is the nurse engaging in?

Correct Answer is C

Explanation

The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse?

Correct Answer is B

Explanation

A nurse is caring for a patient that has limited mobility and spends majority of their day in bed or a chair. The nurse recognizes that the patient would be at risk for which of the following? (Select all that apply)

During rounds a client is having difficulty telling the nurse what they need. The nurse asks her to show her what she needs. The patient points to the bathroom door, signifying she needs to use the restroom. What type of language difficulty is this patient experiencing?

Nurses who assist clients to deal holistically with their health care needs at the end of their lives work primarily in which health care delivery system?

The nurse takes a client's vital signs and finds the pulse rate to be 120 bpm. What would the nurse do next to interpret and analyze this pulse rate?

The nurse understands that patients who are continuously deprived of REM sleep are at highest risk for:

A patient is to have peak and trough levels drawn for a particular drug. The nurse explains to the patient that these drug blood levels are important to:

A client who has to undergo a parathyroidectomy is worried about possibly having to wear a scarf around the neck after surgery. What nursing diagnosis should the nurse document in the care plan?

During an assessment, the nurse notices clouding of the lens of the left eye, and the client reports blurred and hazy vision in the eye. These findings suggest which of the following?