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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Correct Answer is A

Explanation

A. Sitting up and leaning forward helps improve lung expansion and ventilation, which is beneficial for clients with COPD.

B. Elevating the head is helpful but not as effective as sitting upright for COPD clients who need to improve their ventilation.

C. The Trendelenburg position is not appropriate for improving ventilation in COPD patients.

D. While high-Fowler's may help in some situations, having the knees flexed can restrict the diaphragm and limit breathing capacity.

A. "I am glad that these tubes will fall out at home when I finally shower." B. "I should measure the drainage each day to make sure it is less than an ounce (30 mL)." C. "I should be careful how I lie in bed so that I will not kink the tubing." D. "If there is a foul odor from the drainage, I will contact my primary health care provider."

Correct Answer is A

Explanation

A. This statement indicates that the client may not fully understand the care required for the drainage tubes. Drainage tubes typically do not "fall out" on their own; they need to be removed by a healthcare provider. The client should be instructed to care for the tubes, monitor drainage, and report any concerns to their healthcare provider.

B. It is appropriate to measure the drainage each day and report it if it exceeds the expected amount. This helps ensure that the surgical site is healing properly.

C. The client should be cautious with the positioning of the drainage tubes to avoid kinking or pulling, which could interfere with drainage and cause complications.

D. A foul odor from the drainage could indicate an infection, so it is appropriate for the client to contact their primary healthcare provider if this occurs.

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

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