Nokea
A client with end-stage renal disease (ESRD is scheduled for hemodialysis. Which laboratory value should the nurse monitor closely before the procedure?
- A. Serum creatinine
- B. Serum potassium
- C. Serum sodium
- D. Hemoglobin
Correct Answer: B
Rationale: Before hemodialysis in a client with end-stage renal disease (ESRD), monitoring serum potassium closely is crucial. ESRD patients are at risk of hyperkalemia, which can lead to severe cardiac complications. Checking serum potassium levels helps in assessing and managing this electrolyte imbalance. Serum creatinine (Choice A) is a marker of kidney function but is not the most critical value to monitor before hemodialysis. Serum sodium (Choice C) may be affected in renal disease, but potassium is a more crucial electrolyte to monitor. Hemoglobin (Choice D) is essential for assessing anemia in ESRD but is not the primary focus before hemodialysis.
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During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first?
- A. Give the client 4 ounces of orange juice
- B. Call 911 to summon emergency assistance
- C. Check the client for lacerations or fractures
- D. Assess client's blood sugar level
Correct Answer: C
Rationale: The correct first action for the nurse to take after an elderly client with diabetes slips and falls is to check the client for lacerations or fractures. This is crucial to assess for any immediate physical injuries that may need immediate attention. Giving orange juice or assessing the blood sugar level may be important later but checking for injuries takes precedence to ensure the client's safety and well-being. Calling 911 should be considered if there are severe injuries or if the client is in distress, but checking for lacerations or fractures is the priority at the moment.
An adult male who fell from a roof and fractured his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse?
- A. Weak palpable distal pulses
- B. Pain at the fracture site
- C. Mild swelling of the leg
- D. Bruising around the fracture site
Correct Answer: A
Rationale: In a patient with a fractured femur, weak palpable distal pulses can indicate compromised circulation to the lower extremity. This finding suggests a potential vascular compromise that requires immediate intervention to prevent further complications like compartment syndrome or ischemia. Pain at the fracture site, mild swelling of the leg, and bruising around the fracture site are expected following such an injury and surgical stabilization, and while they should be monitored, they do not require immediate intervention like addressing compromised circulation.
A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which laboratory value is most concerning?
- A. Serum potassium of 6.5 mEq/L
- B. Serum sodium of 135 mEq/L
- C. Serum creatinine of 2.0 mg/dl
- D. Blood glucose of 150 mg/dl
Correct Answer: A
Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with CKD as it indicates hyperkalemia, which requires immediate intervention to prevent cardiac complications. Hyperkalemia can lead to life-threatening arrhythmias, particularly in patients with impaired kidney function. Serum sodium, creatinine, and blood glucose levels, while important, are not as acutely dangerous as severe hyperkalemia in this context.
A client with cirrhosis is admitted with jaundice and ascites. Which clinical finding is most concerning?
- A. Increased abdominal girth
- B. Confusion and altered mental status
- C. Yellowing of the skin
- D. Peripheral edema
Correct Answer: B
Rationale: Confusion and altered mental status are concerning in a client with cirrhosis as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Increased abdominal girth can be seen in ascites, yellowing of the skin is due to jaundice, and peripheral edema is associated with fluid retention in cirrhosis, but confusion and altered mental status are more closely linked to hepatic encephalopathy, which can progress rapidly and needs urgent attention.
A client with a spinal cord injury at the T1 level is admitted with a suspected deep vein thrombosis (DVT) in the right leg. Which intervention should the nurse implement first?
- A. Administer prescribed anticoagulant therapy
- B. Place the client on bedrest
- C. Elevate the client's right leg
- D. Apply compression stockings to the right leg
Correct Answer: B
Rationale: The correct answer is to place the client on bedrest. Placing the client on bedrest is the priority intervention as it helps prevent the risk of embolization from the DVT, which could lead to a life-threatening pulmonary embolism. Administering anticoagulant therapy, elevating the client's right leg, or applying compression stockings are important interventions in managing DVT but should come after ensuring the client is on bedrest to prevent the dislodgment of the clot.