The nurse working on a medical surgical unit is assigned four clients at the start of their shift. What client should be given the highest priority?

A 47-year-old client who reports two loose stools with a serum sodium of 139 mmol/L

A 71-year-old client with a calcium level of 8.9 mg/dL and a negative Trousseau sign

A 52-year-old client with fluid volume excess and BUN of 18 mg/dL

A 60-year-old client with a serum potassium of 3.2 mEq/L and heart palpitations

Answer and Explanation

The Correct Answer is D

A. A 47-year-old client who reports two loose stools with a serum sodium of 139 mmol/L: Although diarrhea can lead to electrolyte imbalances, a serum sodium level of 139 mmol/L is within normal range, so this client is not the highest priority.
B. A 71-year-old client with a calcium level of 8.9 mg/dL and a negative Trousseau sign: A calcium level of 8.9 mg/dL is slightly low but not critically low, especially with a negative Trousseau sign. This client is stable compared to others.
C. A 52-year-old client with fluid volume excess and BUN of 18 mg/dL: A BUN of 18 mg/dL indicates mild elevation, and fluid volume excess can be managed with adjustments in treatment; this client does not require immediate priority.
D. A 60-year-old client with a serum potassium of 3.2 mEq/L and heart palpitations: A potassium level of 3.2 mEq/L indicates hypokalemia, which can cause serious cardiac issues and symptoms like palpitations. This client requires urgent attention to address the potential risk of cardiac complications.

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

Explanation

A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This is a sign of infiltration as fluid accumulates in the tissue around the IV site.
C. The vein is firm and cord-like: This is indicative of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a clear sign of infiltration, where fluid leaks out of the vein into surrounding tissue.
E. Warmth at the insertion site: This can be a sign of infiltration or inflammation, depending on the context.

A. Pulmonary embolism B. Pneumonia C. Hemorrhage D. Myocardial infarction

Correct Answer is A

Explanation

A. Pulmonary embolism: Pulmonary embolism presents with sudden onset of chest pain, tachycardia, hypotension, and restlessness, which aligns with the client's symptoms. It is a common postoperative complication due to immobility and potential hypercoagulability.
B. Pneumonia: Pneumonia typically develops more gradually and presents with fever, productive cough, and respiratory distress rather than sudden chest pain and hemodynamic instability. It is less likely in the immediate postoperative period.
C. Hemorrhage: Hemorrhage would also cause tachycardia and hypotension, but it would typically present with symptoms such as excessive bleeding, swelling at the surgical site, and pallor rather than chest pain.
D. Myocardial infarction: While myocardial infarction can cause chest pain, tachycardia, and hypotension, it is less likely in this scenario compared to a pulmonary embolism, given the timing and nature of the symptoms in the immediate postoperative period.

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The nurse working on a medical surgical unit is assigned four clients at the start of their shift. What client should be given the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

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

Explanation

The nurse is rounding on a client who is 12 hours postoperative. Upon assessment, the client becomes tachycardic, hypotensive, and restless and complains of sudden chest pain. Which postoperative complication should the nurse conclude that the client most likely experienced?

Correct Answer is A

Explanation

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The nurse is providing care for several clients at risk for acid-base imbalance. Which client has the greatest risk for respiratory acidosis?

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