After receiving change-of-shift report, which client should the nurse assess first?

Client with serum phosphorus level of 4.5 mg/dL.

Client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes.

Client with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping.

Client with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water.

Answer and Explanation

The Correct Answer is B

A. Client with serum phosphorus level of 4.5 mg/dL: This is within the normal range for phosphorus (2.5-4.5 mg/dL), and the client does not require immediate assessment.

B. Client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes: This is the correct answer. A magnesium level of 1.1 mEq/L is below the normal range (1.5-2.5 mEq/L), and symptoms like tremors and hyperactive reflexes indicate hypomagnesemia, which can lead to serious complications such as arrhythmias.

C. Client with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping: A potassium level of 5.0 mEq/L is within the normal range (3.5-5.0 mEq/L), so this client does not need immediate intervention.

D. Client with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water: A sodium level of 145 mEq/L is at the upper end of normal (135-145 mEq/L), and the symptoms are likely due to dehydration or a normal response.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "They will circulate my blood on a machine during the surgery.": This is correct information regarding the use of a heart-lung machine during CABG.

B. "I will need to take an aspirin every day after the surgery to keep the graft open.": Daily aspirin therapy is standard to prevent graft occlusion, indicating correct understanding.

C. "They will use an artery near my heart to go around the area that is blocked.": This accurately describes using the internal mammary artery for the bypass, showing correct knowledge.

D. "I will have small incisions in my leg where they will remove the vein.": This indicates confusion, as the internal mammary artery, not leg veins, is used in this type of CABG.

A. Ask Mrs. Smith where her husband is right now. B. Explain that the chart must contain an error. C. Apologize and declare confusion about the client. D. Ask the client about preferred forms of address.

Correct Answer is D

Explanation

A. Assuming the client is someone else's spouse based on a name may be inappropriate and could lead to misunderstanding.

B. The chart may not necessarily contain an error, and jumping to conclusions could be unprofessional.

C. Apologizing and declaring confusion may make the client uncomfortable. It's more respectful to inquire directly.

D. Asking the client about their preferred form of address is the most respectful and professional approach.

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After receiving change-of-shift report, which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When evaluating the effectiveness of preoperative teaching with a client scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the client says which of the following?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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