Nokea
A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?
- A. Encourage oral fluid intake
- B. Connect the client to a cardiac monitor
- C. Assess the client's urine output
- D. Administer oral calcitonin (Calcimar)
Correct Answer: B
Rationale: This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes.
You may also like to solve these questions
A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
- A. Measure the client's pulse and blood pressure
- B. A 5-year-old who is cognitively impaired
- C. Applying oxygen by mask or nasal cannula
- D. Increase oral fluid intake
Correct Answer: D
Rationale: For a client with dehydration-induced confusion, the priority is to address the dehydration by increasing fluid intake to restore hydration status, which may help resolve confusion. Measuring vital signs, assessing cognitive status, or applying oxygen may be secondary actions but do not directly address the underlying cause of dehydration.
A nurse is assessing a client on a medical-surgical unit. Which client is at risk for hypokalemia?
- A. Client with pancreatitis who has continuous nasogastric suctioning
- B. Client with a prescription for an angiotensin-converting enzyme (ACE) inhibitor
- C. Client in a motor vehicle crash who is receiving 2 units of packed red blood cells
- D. Client with uncontrolled diabetes and a serum pH level of 7.33
Correct Answer: A
Rationale: A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia due to the removal of potassium-rich gastric fluids.
A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?
- A. Assess the client's respiratory rate, rhythm, and depth
- B. Measure the client's pulse and blood pressure
- C. Document findings and monitor the client
- D. Contact the health care provider
Correct Answer: A
Rationale: In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication is respiratory insufficiency, so a respiratory assessment is the priority.
A client at risk for developing hyperkalemia states, 'I love fruit and usually eat it every day, but now I can't because of my high potassium level.' How should the nurse respond?
- A. Potatoes and avocados can be substituted for fruit
- B. Fruit is universally high in potassium
- C. Berries, cherries, apples, and peaches are low in potassium
- D. You are correct. Fruit is very high in potassium
Correct Answer: C
Rationale: Not all fruits are potassium-rich. Berries, cherries, apples, and peaches are relatively low in potassium and can be included in the diet of a client at risk for hyperkalemia.
After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?
- A. Toasted English muffin with butter and blueberry jam, and tea with sugar
- B. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
- C. Sausage, whole-wheat toast, half cup of raisins, and a glass of milk
- D. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee
Correct Answer: C
Rationale: Meat, dairy products, and dried fruit have high concentrations of potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of high-potassium items.