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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B"]
Explanation
B. Temperature 38.6°C (101.4°F): An elevated temperature in the postoperative period may indicate an infection, which requires immediate evaluation and management.
A. Heart rate 72 beats/min: This is within the normal range and does not indicate an urgent issue.
C. Surgical dressing dry and intact: This is a positive finding and does not require immediate attention.
D. Pain rating 3 out of 10: This level of pain is manageable and does not indicate a severe issue.
E. Limited ambulation: Limited ambulation is expected post-surgery and does not necessarily indicate an urgent problem.
Correct Answer is ["A","C","D"]
Explanation
A. Record intake and output: This task is within the UAP's scope of practice as it involves documenting fluid balance.
B. Assess bowel sounds: This task requires clinical judgment and assessment skills and should be performed by a licensed nurse.
C. Obtain routine vital signs: This is appropriate for the UAP to perform, as it involves routine measurements that do not require clinical assessment.
D. Document the presence of edema: The UAP can document observable findings such as edema, which is within their scope of practice.
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