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 B

Explanation

A) Fasting plasma glucose of 98 mg/dl:
A fasting plasma glucose level of 98 mg/dl is within the normal range (70–99 mg/dl). According to diagnostic criteria, a fasting plasma glucose level of 100–125 mg/dl is considered prediabetes, and 126 mg/dl or higher on two separate occasions is diagnostic for diabetes. Therefore, a fasting plasma glucose of 98 mg/dl is not diagnostic for diabetes.

B) Hemoglobin A1C (glycosylated hemoglobin) of 7.2%:
An HbA1C level of 7.2% is diagnostic for diabetes. The American Diabetes Association (ADA) defines diabetes as an HbA1C of 6.5% or higher. The HbA1C test reflects the average blood glucose level over the past 2–3 months, and a level of 7.2% indicates that the patient's blood glucose levels have been elevated over time, consistent with diabetes. This is a key diagnostic criterion.

C) Random plasma glucose of 110 mg/dl:
Although a random glucose value greater than 200 mg/dl with symptoms of hyperglycemia can be diagnostic of diabetes, 110 mg/dl is within the normal range and does not meet the criteria for a diabetes diagnosis. For diagnostic purposes, a random plasma glucose must be 200 mg/dl or higher.

D) Two hour plasma glucose of 140 mg/dl:
For the test to be diagnostic of diabetes, the plasma glucose must be 200 mg/dl or higher after two hours. A level of 140 mg/dl suggests normal glucose tolerance or prediabetes, but it is not diagnostic for diabetes.

A. Having 2 RNs ensure the blood product is properly labeled and matches the client’s identification B. Ensuring that the client signed a consent form for receiving blood transfusions beforehand C. Preparing a primary and secondary IV tubing D. Obtaining a bag of 0.9% sodium chloride

Correct Answer is C

Explanation

A) Having 2 RNs ensure the blood product is properly labeled and matches the client’s identification:
Two registered nurses must independently verify that the blood product matches the patient's identification and that it is properly labeled. This is a critical safety measure to prevent errors, such as mismatched blood transfusions, which can lead to severe complications like hemolytic reactions. Proper verification before administration is a standard safety protocol in blood transfusion procedures.

B) Ensuring that the client signed a consent form for receiving blood transfusions beforehand:
Obtaining informed consent is a vital legal and ethical step before administering a blood transfusion. The nurse must ensure that the patient understands the potential risks and benefits of the procedure and has signed a consent form prior to transfusion. Without consent, the transfusion cannot legally be performed. This is a key part of patient rights and nursing responsibilities.

C) Preparing a primary and secondary IV tubing:
For blood transfusions, only blood administration tubing should be used, which typically includes a filter to prevent the infusion of any debris or clots. Using regular IV tubing (primary and secondary) for blood administration is not recommended, as it may not have the necessary filter and could potentially introduce contaminants. Blood should always be administered with tubing specifically designed for that purpose.

D) Obtaining a bag of 0.9% sodium chloride:
Normal saline is typically used as the solution to flush the IV line before and after the transfusion. It is compatible with blood products and helps to prevent clotting or reactions in the line. This is an essential step to ensure safe and effective blood administration.

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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

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The nurse in a clinic reviewing laboratory results for a patient suspected of having undiagnosed diabetes mellitus. Which of the following results would be diagnostic for diabetes

Correct Answer is B

Explanation

Which of the following would not be an appropriate nursing intervention when preparing to administer a blood transfusion?

Correct Answer is C

Explanation

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