The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take?

Auscultate for irregular heart rate.

Monitor daily sodium intake.

Document abdominal girth.

Measure ankle circumference

Answer and Explanation

The Correct Answer is A

A)   Correct- Electrolyte imbalances, particularly involving electrolytes like potassium, can lead to cardiac arrhythmias. Elevated blood pressure can strain the cardiovascular system, and mental status changes could indicate potential neurologic and cardiovascular involvement. Auscultating for an irregular heart rate helps identify any immediate cardiac issues that require intervention.
B)   Incorrect- While monitoring sodium intake is important for clients with chronic kidney disease, it is not the most urgent action in this scenario. The presence of electrolyte imbalance, elevated blood pressure, and changes in mental status indicate a more acute concern that requires immediate assessment.
C)   Incorrect- Documenting abdominal girth is relevant for assessing fluid status, but in this situation, the presence of electrolyte imbalance, elevated blood pressure, and mental status changes indicates a more critical issue that requires prompt intervention.

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Correct Answer is D

Explanation

A) Incorrect- While the history of vomiting is important to assess, it may not be the most crucial information to gather at this point, as the client is postoperative and the focus is on immediate postoperative care.
B) Incorrect- While assessing for fluid intake is important, the client's refusal of ice chips is not an urgent concern compared to other potential complications, such as pain management, oxygenation, and fluid balance.
C) Incorrect- These assessments are important, but the client's history of right hemicolectomy and the current infusion and medication administration require closer attention to fluid balance, pain control, and oxygenation.
D) Correct- While all options are important to consider, the most critical information in this scenario is assessing peripheral pulses and the range of motion of both legs. A right hemicolectomy involves abdominal surgery and decreased or absent peripheral pulses along with a limited range of motion could indicate impaired circulation, thrombosis, or other post-operative complications. These findings might necessitate prompt intervention to prevent potential complications.

A. Contact information for community resources B. Information about pool safety C. A warning about potential charges for child neglect D. When to follow up with the child's pediatrician E. Instructions on how to access long-term home care F. Assessment of the parent's coping skills

Correct Answer is ["A","B","D"]

Explanation

A) Correct - Providing contact information for community resources is important as it ensures that parents have access to support and information beyond the hospital setting.

B) Correct - Offering information about pool safety is relevant, especially considering that the child experienced a submersion injury. This education can help prevent future accidents.
C) Incorrect - While discussing child neglect is important, it may not be the most appropriate time to bring up potential charges. The immediate focus should be on education and support.
D) Correct - Informing parents about when to follow up with the child's pediatrician ensures continuity of care and monitoring of the child's condition after discharge.
E) Incorrect - Instructions on how to access long-term home care may not be necessary if the child's condition does not warrant it. This option can be excluded based on the information provided.
F) Incorrect - Assessing the parent's coping skills is important, but it is not part of pre- discharge education. Education related to the child's condition and safety is more pertinent.

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The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is ["A","B","D"]

Explanation

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