Nokea
A client just been diagnosed with acute kidney injury has a serum potassium level of 6.1 mEq/L (6.1 mmol/L). Which action should the nurse take immediately?
- A. Check the sodium level.
- B. Call the primary health care provider.
- C. Encourage an extra 500 mL of fluid intake.
- D. Teach the client about foods low in potassium.
Correct Answer: B
Rationale: The client with hyperkalemia is at risk of developing cardiac dysrhythmias and resultant cardiac arrest. Because of this, the primary health care provider must be notified at once so that the client may receive definitive treatment. The nurse might also check the result of a serum sodium level, but this is not a priority action of the nurse. Fluid intake would not be increased because it would contribute to fluid overload and would not effectively lower the serum potassium level. Dietary teaching may be necessary at some point, but this action is not the priority.
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Which of the following terms is used to describe the sound, timely, smooth, unfragmented and seamless transition of the client from one level of acuity to another?
- A. Case management
- B. Continuity of care
- C. Medical necessity
- D. Critical pathway
Correct Answer: B
Rationale: Continuity of care refers to the seamless, coordinated transition of a client across different levels of care, ensuring consistent and effective treatment.
The nurse is caring for a client with a ventricular shunt for hydrocephalus. Which finding requires immediate reporting?
- A. Clear drainage from the incision
- B. Mild headache
- C. Temperature of 98.6°F (37°C)
- D. Pupils equal and reactive
Correct Answer: A
Rationale: Clear drainage from a shunt incision may indicate cerebrospinal fluid leakage, a serious complication requiring immediate reporting.
A client with a history of schizophrenia is prescribed olanzapine (Zyprexa). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Olanzapine commonly causes weight gain, requiring monitoring.
The nurse reviews the serum laboratory results for a client prescribed hydrochlorothiazide. Which most frequent side effect of this medication should the nurse specifically monitor for?
- A. Hypokalemia
- B. Hypocalcemia
- C. Hypernatremia
- D. Hyperphosphatemia
Correct Answer: A
Rationale: The client taking a potassium-losing diuretic must be monitored for decreased potassium levels. Other fluid and electrolyte imbalances that occur with the use of this medication include hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia.
A client has begun medication therapy with pancrelipase. The nurse should educate the client to expect which occurrence from this medication?
- A. Relieve of heartburn
- B. Eliminate of abdominal pain
- C. Help regulating blood glucose
- D. Decrease in the amount of fat in the stools
Correct Answer: D
Rationale: Pancrelipase is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. It does not regulate blood glucose; this is a function of insulin, a hormone produced in the beta cells of the pancreas.