The nurse is renewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L, Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

Obtain a 12 lead ECG

Request an electroencephalogram (FEC)

Assess for Chvostek's sign

Obtain a chest X-ray.

Answer and Explanation

The Correct Answer is A

A) Obtain a 12-lead ECG:
The client’s potassium level of 6.6 mEq/L is significantly elevated which places the patient at risk for cardiac arrhythmias. Elevated potassium levels can cause dangerous changes in the electrical activity of the heart, leading to peaked T waves, widened QRS complexes, and even cardiac arrest. A 12-lead ECG is necessary to assess the heart's electrical activity and to identify any potential arrhythmias

B) Request an electroencephalogram (EEG):
An EEG is used to assess brain activity and is typically indicated for conditions such as seizures or epilepsy. This client’s laboratory findings do not suggest a neurological concern that would warrant an EEG.

C) Assess for Chvostek's sign:
Chvostek's sign is used to assess for hypocalcemia or tetany, where a twitching of the facial muscles occurs upon tapping the facial nerve. However, the client’s primary issue here is elevated potassium levels, which are a more immediate concern than hypocalcemia. Hyperkalemia can have more severe and urgent consequences, particularly for the heart, so Chvostek's sign is not the priority at this time.

D) Obtain a chest X-ray:
A chest X-ray is not indicated based on the client’s current electrolyte imbalance or renal failure status. While a chest X-ray may be useful for various other concerns, the client’s elevated potassium level is the primary issue, and the priority intervention is to assess and manage the potential for cardiac arrhythmias with a 12-lead ECG.

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Correct Answer is D

Explanation

Moderate sedation (also called conscious sedation) involves the administration of medications (e.g., midazolam, fentanyl, or propofol) to reduce anxiety, pain, and awareness during procedures, while allowing the patient to:

Remain awake but relaxed
Respond to verbal commands
Maintain their own airway without the need for intubation

It is commonly used for minor surgical procedures, endoscopies, and dental procedures.

A. Sedate the client with PRN medications so they stay in bed B. Implement the bed alarm and call light system C. Ensure all four side rails on the bed are up D. Avoid night lights in the client's room to promote sleep

Correct Answer is B

Explanation

A. Sedate the client with PRN medications so they stay in bed:
Sedating a client to prevent movement is not an appropriate intervention for fall prevention. This approach could have adverse effects, such as increased confusion, sedation, and even a greater risk for falls once the medication wears off. It may also contribute to a decreased level of independence and quality of life for the client. Non-pharmacological interventions such as environmental modifications and supportive devices should be prioritized.

B. Implement the bed alarm and call light system:
Implementing a bed alarm and call light system is an effective and appropriate strategy to prevent falls in an older adult client. The bed alarm alerts the healthcare team when the client attempts to get out of bed, reducing the risk of falls. The call light allows the client to request assistance before attempting to move independently, ensuring timely support and reducing fall risk. This intervention promotes safety while maintaining the client’s autonomy.

C. Ensure all four side rails on the bed are up:
While side rails may prevent a client from falling out of bed, raising all four side rails can increase the risk of injury. Clients may try to climb over the rails, which can lead to entrapment or falls. In addition, side rails can create a false sense of security and reduce the client's ability to mobilize independently. A more appropriate measure would be using one or two side rails or providing assistance with repositioning or transferring when necessary.

D. Avoid night lights in the client's room to promote sleep:
Avoiding night lights is not advisable for older adults, particularly those at risk for falls. A dark environment can increase confusion and disorientation, leading to unsafe movements. Providing soft night lights in the room can enhance visibility during nighttime hours, reducing the likelihood of accidents and falls when the client needs to get up to use the bathroom or reposition. Adequate lighting is a key aspect of fall prevention.

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The nurse is renewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L, Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a student on moderate/conscious sedation. Which of the following is a correct statement about moderate sedation?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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