Which finding is the most concerning and should prompt immediate action by the nurse?
Potassium level of 4.8 mEq/L
Episodes of dizziness and blurred vision
Chest x-ray showing mild left ventricular hypertrophy
Blood pressure of 168/98 mmHg
The Correct Answer is B
Choice A reason: Potassium of 4.8 mEq/L is within normal range (3.5-5.0 mEq/L), posing no immediate threat. Hyperkalemia risks arrhythmias, but this level doesn’t warrant urgent action, as it’s stable and unlikely to disrupt cardiac function acutely.
Choice B reason: Dizziness and blurred vision suggest cerebral hypoperfusion or stroke, potentially from hypertension or embolism. These neurologic symptoms demand immediate action to assess and treat, as they indicate acute risk to brain function or life.
Choice C reason: Mild left ventricular hypertrophy on x-ray reflects chronic hypertension adaptation, not an acute emergency. It’s a stable finding requiring management, but it doesn’t necessitate immediate intervention compared to symptomatic neurologic changes.
Choice D reason: Blood pressure of 168/98 mmHg is elevated (stage 2 hypertension), risking long-term damage. Without acute symptoms, it’s less urgent than dizziness and vision changes, which signal immediate compromise needing rapid response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: CF-related diabetes (CFRD) from pancreatic damage requires insulin, as glucose of 180-250 mg/dL indicates insulin deficiency. Teaching administration addresses this directly, aligning with standard CFRD management for glycemic control.
Choice B reason: Oral hypoglycemics aren’t effective in CFRD, which stems from insulin lack, not resistance. Glucose levels of 180-250 mg/dL need insulin, making this inappropriate for CF’s unique endocrine pathology.
Choice C reason: Diet impacts glucose, but CFRD requires insulin first, not just dietary control. Levels of 180-250 mg/dL exceed dietary management alone, so this is secondary to initiating insulin therapy in CF.
Choice D reason: Pancreatic enzymes aid digestion in CF, not glucose control directly. Evaluating use is routine, but hyperglycemia of 180-250 mg/dL points to CFRD, necessitating insulin over enzyme adjustment.
Correct Answer is D
Explanation
Choice A reason: Restricting fluids to 2 liters per day increases blood viscosity in sickle cell disease, promoting sickling and vaso-occlusion. Adequate hydration is critical to dilute hemoglobin S, so this instruction contradicts evidence-based management for crisis prevention.
Choice B reason: Iron supplements are contraindicated in sickle cell disease unless anemia is iron-deficient, which is rare. Most patients have normal or high iron from hemolysis, so a multivitamin with iron risks overload and organ damage.
Choice C reason: Avoiding caffeine lacks evidence in sickle cell crisis prevention; it’s not a trigger. Moderate intake doesn’t dehydrate significantly or affect sickling, making this instruction irrelevant to discharge teaching for this condition.
Choice D reason: Limiting crowd exposure reduces infection risk, a common sickle cell crisis trigger. Infections cause inflammation and hypoxia, promoting sickling, so this instruction aligns with preventing complications and maintaining patient stability post-discharge.
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