After receiving the change of shift report, the nurse reviews the electronic health record for each client. What client should the nurse see first?

The client with a serum phosphorus of 4.5 mg/dL that requires assistance with planning their meals

The client with a serum magnesium of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

The client with a serum potassium of 5.3 mEq/L and is scheduled for hemodialysis in three hours

The client with a serum sodium of 145 mEq/L who is complaining of a dry mouth and wants a glass of water

Answer and Explanation

The Correct Answer is B

A. The client with a serum phosphorus of 4.5 mg/dL that requires assistance with planning their meals: A serum phosphorus level of 4.5 mg/dL is within the normal range, and assistance with meal planning is a lower priority compared to the other situations.
B. The client with a serum magnesium of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes: This client has hypomagnesemia, which can lead to severe complications like seizures or cardiac arrhythmias. Immediate attention is necessary due to the symptoms and the critically low magnesium level.
C. The client with a serum potassium of 5.3 mEq/L and is scheduled for hemodialysis in three hours: This potassium level is slightly elevated, but the scheduled hemodialysis suggests the issue will be addressed soon.
D. The client with a serum sodium of 145 mEq/L who is complaining of a dry mouth and wants a glass of water: A serum sodium of 145 mEq/L is on the high end of normal; the client's dry mouth is concerning but not as urgent as the issues presented by the hypomagnesemia.

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Correct Answer is A

Explanation

A. Low-grade fever: A low-grade fever could indicate an infection or other complications related to TPN or bowel surgery, and it is crucial to report this to the healthcare provider.
B. Fatigue: While fatigue is a common symptom, it is less urgent compared to a potential infection.
C. Anorexia: Anorexia is a concern but is not as immediate as a fever.
D. Hypoactive bowel sounds: This is expected after extensive bowel surgery and may not be as urgent as signs of infection.

A. Neuromuscular blockers B. Inhaled general anesthesia C. Intravenous general anesthesia D. Regional anesthesia

Correct Answer is D

Explanation

A. Neuromuscular blockers: These are used to induce paralysis and do not affect consciousness or maintain reflexes such as the gag reflex.
B. Inhaled general anesthesia: Generally, inhaled general anesthesia suppresses all reflexes, including the gag reflex.
C. Intravenous general anesthesia: This type of anesthesia typically induces a loss of consciousness and suppression of reflexes, including the gag reflex.
D. Regional anesthesia: This type of anesthesia blocks sensation in a specific area of the body while the client remains conscious and retains reflexes, including the gag reflex.

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After receiving the change of shift report, the nurse reviews the electronic health record for each client. What client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is assessing a client receiving TPN infusion for malabsorption after extensive bowel surgery. What finding is most important for the nurse to report to the health care provider?

Correct Answer is A

Explanation

The nurse is educating a group of student nurses about the different types of anesthesia. The student demonstrates an understanding of the teaching when they state that a client would maintain a gag reflex with what anesthesia?

Correct Answer is D

Explanation

A client has a serum calcium level of 12.8 mg/dL. Which medication will likely be prescribed for this client?

A client with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding related to the imbalance indicates that the client's compensatory mechanisms are working?

The nurse is providing teaching to the client about the use of vitamins and supplements. The nurse would state that vitamin D has a major role in which process?

The client has received IV solution for three (3) days through a 20-gauge IV catheter placed in the left hand. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

A client is scheduled for surgery at 0800 and has been NPO (nothing by mouth) since midnight. They have been taking long-term oral steroids and are scheduled for their routine dose of Prednisone 30 mg PO to be administered at 0600. Which nursing action is most appropriate?