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 ["A","B","C"]

Explanation

A. Jugular vein distention is a common sign of fluid volume overload, as increased central venous pressure causes distention of the jugular veins.
B. Crackles heard during auscultation indicate pulmonary congestion or edema, a hallmark of fluid volume overload.
C. Dyspnea results from fluid accumulation in the lungs, impairing oxygen exchange and causing difficulty breathing.
D. Hypotension is not a sign of hypervolemia; instead, hypervolemia typically causes hypertension due to increased circulating volume.
E. Flat veins are indicative of hypovolemia, not hypervolemia. In hypervolemia, veins are typically distended due to the excess fluid volume.

A. Orthostatic hypotension B. WBCs of 83 C. Lack of appetite for 2 days D. Abdominal cramping

Correct Answer is B

Explanation

A. Orthostatic hypotension can be concerning, but it is not as immediately alarming as a very elevated WBC count. It could indicate dehydration or blood loss, which are common in Crohn's disease exacerbations, but it is not as critical as an infection or severe inflammation.
B. A WBC count of 83 (normal range is typically 4,000-11,000) is significantly elevated and suggests a severe infection or inflammatory response, which is a critical concern in Crohn's disease exacerbations. This could indicate a life-threatening complication such as an abscess or perforation.
C. Lack of appetite for 2 days is common during an exacerbation of Crohn's disease, though it can contribute to dehydration or malnutrition, it is not as immediately concerning as an elevated WBC count.
D. Abdominal cramping is a typical symptom of Crohn's disease and may worsen during exacerbations, but it is not the most concerning finding compared to a severely elevated WBC count.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an infusion of intravenous fluids to a client who is at risk for fluid volume overload. Which of the following manifestations would indicate hypervolemia? (Select all that apply)

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

Explanation

Which of the following signs and symptoms from a client who came to the clinic for an exacerbation of Crohn's Disease is the most concerning?

Correct Answer is B

Explanation

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