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

Request a CT scan of the head.

Assess for Chvostek’s sign.

Obtain a chest X-ray.

Obtain a 12-lead ECG.

Answer and Explanation

The Correct Answer is D

A. A CT scan of the head is not indicated based on the laboratory findings provided. The priority intervention is related to the elevated potassium level.
B. Chvostek’s sign is associated with hypocalcemia (low calcium levels), not hyperkalemia (high potassium levels).
C. A chest X-ray is not the priority intervention for elevated potassium. The primary concern is the potential for cardiac arrhythmias related to the high potassium level.
D. Hyperkalemia (potassium 6.6 mEq/L) can lead to cardiac arrhythmias. The nurse should obtain a 12-lead ECG to assess for any changes in the heart's electrical activity, which could indicate serious complications like arrhythmias or cardiac arrest.

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Correct Answer is D

Explanation

A. A client with heart failure and crackles in the lungs is more likely to have fluid volume excess rather than deficit.
B. A client with renal failure and pitting edema is typically at risk for fluid retention and overload, not deficit.
C. Being NPO for 4 hours is unlikely to cause significant fluid volume deficit, as this is a short period without oral intake.
D. A client with Crohn's disease experiencing diarrhea is losing significant fluids and electrolytes, placing them at high risk for fluid volume deficit. Diarrhea is a common cause of dehydration and requires close monitoring.

A. Respiratory depression B. Tachycardia C. Urinary frequency D. Constipation E. Hypotension

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

Explanation

A. Respiratory depression is a common and serious side effect of opioid medications. The patient's respiratory rate is 11 breaths per minute, which is on the low end of normal and could be further depressed by additional opioid administration, increasing the risk of respiratory compromise.
B. Tachycardia is not a typical side effect of opioids. The patient’s heart rate is 72 beats per minute, which is within normal limits, and there is no indication of tachycardia.
C. Urinary frequency is unlikely to be caused by opioids. In fact, opioids can lead to urinary retention, not frequency, and the patient's urinary output is already low (480 mL in 12 hours), suggesting potential urinary retention.
D. Constipation is a common side effect of opioid use. The patient has not had a bowel movement in three days, and absent bowel sounds suggest the possibility of opioid-induced constipation.
E. Hypotension is a known side effect of opioids. The patient’s blood pressure is 90/54, which is on the low side, indicating that further opioid administration could exacerbate hypotension.

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

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Naxlex Comprehensive Predictor Exams

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

Correct Answer is D

Explanation

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

Explanation

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