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A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which laboratory value should the nurse report to the healthcare provider before the procedure?
- A. Serum potassium of 5.5 mEq/L
- B. Hemoglobin of 10 g/dl
- C. Potassium of 6.0 mEq/L
- D. Blood glucose of 200 mg/dl
Correct Answer: C
Rationale: The correct answer is C: Potassium of 6.0 mEq/L. A potassium level of 6.0 mEq/L is dangerously high in a client with CKD, and it should be reported before hemodialysis to prevent cardiac complications. High potassium levels can lead to life-threatening arrhythmias. Choices A, B, and D are not the most critical values to report before hemodialysis. While a serum potassium level of 5.5 mEq/L is slightly elevated, it is not as urgent as a level of 6.0 mEq/L in this context. Hemoglobin of 10 g/dl and blood glucose of 200 mg/dl are important parameters to monitor but are not as immediately concerning before hemodialysis compared to a high potassium level.
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The nurse is caring for a client with end-stage renal disease (ESRD) who is scheduled for hemodialysis. Which clinical finding is most concerning?
- A. Blood pressure of 110/70 mmHg
- B. Heart rate of 110 beats per minute
- C. Fever of 100.4°F
- D. Respiratory rate of 24 breaths per minute
Correct Answer: C
Rationale: The correct answer is C. A fever of 100.4°F is most concerning in a client with ESRD scheduled for hemodialysis because it may indicate an underlying infection that requires immediate attention. Elevated body temperature can be a sign of systemic infection, which can quickly worsen in individuals with compromised renal function. Monitoring for infection is crucial in ESRD patients to prevent complications. Choices A, B, and D are not as immediately concerning in this context. While variations in blood pressure, heart rate, and respiratory rate should be monitored, they are not as indicative of a potentially severe issue as an unexplained fever in this scenario.
The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 28 breaths per minute
- C. Tidal volume of 300 ml
- D. Blood pressure of 110/70 mmHg
Correct Answer: C
Rationale: The correct answer is C. A tidal volume of 300 ml is concerning in a client with ARDS on mechanical ventilation because it indicates hypoventilation, which can lead to inadequate gas exchange and worsening respiratory status. This finding requires immediate intervention to optimize ventilation and oxygenation. Options A, B, and D are not as critical in this scenario. An oxygen saturation of 90% may be acceptable depending on the client's baseline condition and the target range set by the healthcare provider. A respiratory rate of 28 breaths per minute is slightly elevated but may not be immediately alarming. A blood pressure of 110/70 mmHg is within normal limits and does not require urgent intervention.
A client with a postoperative wound that eviscerated yesterday has an elevated temperature. What is the most important intervention for the nurse to implement?
- A. Initiate contact isolation.
- B. Obtain a wound swab for culture and sensitivity.
- C. Assess temperature every 4 hours.
- D. Use alcohol-based solutions for hand hygiene.
Correct Answer: B
Rationale: Obtaining a wound swab for culture and sensitivity is the most important intervention in this situation. It helps identify the presence of infection in the postoperative wound that could be causing the elevated temperature. By obtaining a wound swab, healthcare providers can determine the appropriate treatment needed to address any infection. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case. Assessing temperature (Choice C) is important but does not directly address the underlying cause of the elevated temperature. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but is not the most crucial intervention in this scenario.
The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which intervention should the nurse implement first?
- A. Encourage fluid intake to thin secretions.
- B. Administer a mucolytic agent.
- C. Increase humidity in the client's room.
- D. Perform deep suctioning as needed.
Correct Answer: C
Rationale: Increasing humidity in the client's room is the first priority in managing thick, tenacious secretions in a client with a tracheostomy to facilitate airway clearance. This intervention helps to moisten secretions, making them easier to clear. Encouraging fluid intake (Choice A) can be beneficial, but increasing humidity should be addressed first. Administering a mucolytic agent (Choice B) and performing deep suctioning (Choice D) are interventions that can be considered after addressing humidity if necessary, but they are not the initial priority.
A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling 'very tired'. Which nursing intervention is most important for the nurse to implement?
- A. Measure vital signs
- B. Auscultate breath sounds
- C. Palpate the abdomen
- D. Observe the skin for bruising
Correct Answer: A
Rationale: The correct answer is to measure vital signs. Abrupt withdrawal of exogenous corticosteroids can precipitate adrenal insufficiency, potentially leading to shock. Monitoring vital signs is crucial in identifying any signs of adrenal insufficiency, such as hypotension or tachycardia. Auscultating breath sounds (choice B) may be important in other situations, such as respiratory conditions, but it is not the priority in this case. Palpating the abdomen (choice C) and observing the skin for bruising (choice D) are not directly related to the potential complications of corticosteroid withdrawal and adrenal insufficiency.