Nokea
After receiving change-of-shift report, which patient should the nurse assess first?
- A. Patient with a serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping
- B. Patient with a serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water
- C. Patient with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
- D. Patient with a serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates
Correct Answer: C
Rationale: The correct answer is patient C with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures, which are life-threatening. Assessing and addressing this patient's condition promptly is crucial to prevent complications. Patients A, B, and D have mild electrolyte disturbances or symptoms that require attention, but they are not at immediate risk for life-threatening complications like seizures, unlike patient C.
You may also like to solve these questions
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
- A. Increase fluids if your mouth feels dry.
- B. More fluids are needed if you feel thirsty.
- C. Drink more fluids in the late evening hours.
- D. If you feel lethargic or confused, you need more to drink.
Correct Answer: A
Rationale: The correct answer is A. An alert, older patient can self-assess for signs of dehydration like dry mouth. This instruction is appropriate as it encourages the patient to respond to early signs of dehydration. Choice B is incorrect because the thirst mechanism decreases with age and feeling thirsty may not accurately indicate the need for fluids. Choice C is incorrect as many older patients prefer to limit evening fluid intake to enhance sleep quality. Choice D is incorrect because an older adult who is lethargic or confused may not be able to accurately assess their need for fluids.
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?
- A. Pallor
- B. Edema
- C. Confusion
- D. Restlessness
Correct Answer: B
Rationale: The correct answer is B: Edema. The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels. Pallor is more commonly seen in anemia, confusion and restlessness may be related to other issues like electrolyte imbalances or neurological conditions.
A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?
- A. Obtain the baseline weight
- B. Check the patient's blood pressure
- C. Draw blood for serum electrolyte levels
- D. Ask about any extremity numbness or tingling
Correct Answer: B
Rationale: The correct answer is to check the patient's blood pressure. Given the patient's symptoms of frequent, watery stools, there is a concern for fluid volume deficit. Assessing the blood pressure helps determine the patient's perfusion status, which is crucial in managing fluid volume deficits. While obtaining baseline weight, drawing blood for serum electrolyte levels, and asking about extremity numbness or tingling are important assessments, checking the blood pressure takes precedence as it provides immediate information on the patient's circulatory status.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
- A. Discontinue the nasogastric suction.
- B. Give the patient the PRN IV morphine sulfate 4 mg.
- C. Notify the health care provider about the ABG results.
- D. Teach the patient how to take slow, deep breaths when anxious.
Correct Answer: B
Rationale: The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.
A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?
- A. Ask the wife how she would like to participate in the client's care
- B. Provide the wife with information about hospice
- C. Encourage the wife to visit after painful treatments are completed
- D. Refer the wife to a support group for family members of those dying of cancer
Correct Answer: A
Rationale: The most beneficial nursing intervention in this situation is to ask the wife how she would like to participate in the client's care. Involving the spouse in the care of the terminally ill client can provide comfort, support, and a sense of contribution during a challenging time. Providing information about hospice (B) is important but may not be the immediate priority. Encouraging the wife to visit after treatments are completed (C) may delay her involvement in the care. Referring her to a support group (D) is a good idea but might be more suitable at a later stage.