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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ensuring an incentive spirometer is available is important for postoperative care to prevent atelectasis, but it is not the priority immediately before surgery.
B. Preoperative teaching is valuable but should ideally be completed earlier in the care process. Last-minute teaching may overwhelm the patient or delay critical interventions.
C. Reporting allergies is essential, but if the allergy to sardines does not pertain to the current surgical plan or medications, it is not the immediate priority in this situation.
D. Administering the preoperative intravenous antibiotic is the top priority because it helps reduce the risk of surgical site infections. Timing of preoperative antibiotics is critical to their effectiveness.
Correct Answer is B
Explanation
A. Flushed skin is typically associated with fever or infection, not with hyponatremia (low sodium levels).
B. Confusion is a common symptom of hyponatremia, especially when sodium levels drop significantly. The low sodium level affects brain function, leading to confusion, altered mental status, and even seizures in severe cases.
C. Extreme thirst is more commonly seen in hypernatremia (high sodium levels) as the body attempts to correct the imbalance by stimulating thirst.
D. Fever is not a direct consequence of hyponatremia but could be associated with an underlying infection or other conditions.
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