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 A

Explanation

A. Tight shoes may indicate fluid retention in the lower extremities, which is a common symptom of right-sided heart failure. This condition leads to the backup of blood into the systemic circulation, causing peripheral edema.

B. Sleeping with two pillows may indicate left-sided heart failure, as the client may be experiencing orthopnea (difficulty breathing when lying flat).

C. Shortness of breath is more commonly associated with left-sided heart failure.

D. Waking up coughing every night is also a sign of left-sided heart failure, where pulmonary congestion leads to nocturnal coughing.

A. Allow the client to suck on small quantities of ice chips. B. Apply oxygen and continuous pulse oximetry. C. Have the respiratory therapist provide humidified room air. D. Request an antitussive medication from the physician.

Correct Answer is B

Explanation

A. Sucking on small quantities of ice chips is not appropriate in this case as it may worsen the airway obstruction or cause further irritation.

B. Applying oxygen and continuously monitoring the client's pulse oximetry will help ensure that the client's oxygen saturation remains adequate and that they do not experience respiratory distress or hypoxemia due to inhalation injury. Early intervention is crucial to prevent worsening of respiratory status.

C. Humidified room air can help in cases of airway irritation, but the priority is to ensure oxygenation and avoid hypoxia.

D. Antitussive medications may be indicated later, but airway management and oxygenation take precedence.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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