Nokea
The client with chronic kidney disease (CKD) is receiving hemodialysis. Which finding should be reported to the healthcare provider immediately?
- A. Blood pressure of 150/90 mm Hg.
- B. Weight gain of 2 pounds since the last dialysis session.
- C. Blood glucose level of 120 mg/dl.
- D. Potassium level of 6.5 mEq/L.
Correct Answer: D
Rationale: The correct answer is D: Potassium level of 6.5 mEq/L. High potassium levels (hyperkalemia) in CKD patients receiving hemodialysis can lead to serious complications like cardiac arrhythmias or even cardiac arrest. Therefore, it is crucial to report this finding immediately to the healthcare provider for prompt intervention.
Explanation for other choices:
A: Blood pressure of 150/90 mm Hg - While elevated, this blood pressure reading is not an immediate concern unless accompanied by symptoms like chest pain or shortness of breath.
B: Weight gain of 2 pounds since the last dialysis session - While weight gain may indicate fluid retention, it is not an urgent issue unless it is rapid and significant.
C: Blood glucose level of 120 mg/dl - A blood glucose level of 120 mg/dl is within the normal range and does not require immediate action in this context.
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A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?
- A. Urine output of 100 mL/hour.
- B. Intracranial pressure (ICP) of 20 mm Hg.
- C. Respiratory rate of 12 breaths/minute.
- D. Mean arterial pressure (MAP) of 70 mm Hg.
Correct Answer: B
Rationale: The correct answer is B: Intracranial pressure (ICP) of 20 mm Hg. Elevated ICP can lead to increased intracranial pressure, which can further damage brain tissue and impair cerebral perfusion. This is a critical finding that requires immediate intervention to prevent further brain damage.
A: Urine output of 100 mL/hour is within the normal range and does not pose an immediate threat to the client's condition.
C: Respiratory rate of 12 breaths/minute is within normal limits and does not indicate an immediate concern.
D: Mean arterial pressure (MAP) of 70 mm Hg is within the normal range for most adults and does not require immediate intervention in this scenario.
Following a CVA, the nurse assesses that a client developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?
- A. Continuous tube feeding at 65 ml/hr via gastrostomy.
- B. Total parenteral nutrition to be infused at 125 ml/hour.
- C. Nasogastric tube connected to low intermittent suction.
- D. Metoclopramide (Reglan) intermittent piggyback.
Correct Answer: A
Rationale: The correct answer is A: Continuous tube feeding at 65 ml/hr via gastrostomy. Dysphagia, hypoactive bowel sounds, and a distended abdomen indicate a potential risk for aspiration or impaired gastrointestinal motility. Continuous tube feeding may worsen these conditions. The nurse should question this prescription to prevent further complications. Choices B, C, and D are not immediate concerns for dysphagia and bowel issues. Total parenteral nutrition, nasogastric tube connected to suction, and metoclopramide can be appropriate interventions for nutritional support and bowel motility in this scenario.
A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a Level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per minute. Which drug is the transport team most likely to administer to this infant?
- A. Ampicillin (Omnipen) 25 mg/kg slow IV push.
- B. Gentamicin sulfate (Garamycin) 2.5 mg/kg IV.
- C. Digoxin (Lanoxin) 20 micrograms/kg IV.
- D. Beractant (Survanta) 100 mg/kg per endotracheal tube.
Correct Answer: D
Rationale: The correct answer is D: Beractant (Survanta) 100 mg/kg per endotracheal tube. In this scenario, the infant's high respiratory rate indicates respiratory distress, likely due to immature lungs. Beractant is a pulmonary surfactant used to treat respiratory distress syndrome in preterm infants by improving lung function and reducing the risk of complications. Administering beractant via endotracheal tube helps deliver the medication directly to the lungs.
Choice A (Ampicillin) is an antibiotic used for treating infections, not respiratory distress. Choice B (Gentamicin) is an antibiotic for infections, not respiratory distress. Choice C (Digoxin) is a cardiac medication for heart conditions, not respiratory distress. Therefore, only choice D addresses the respiratory distress issue in the preterm infant, making it the most appropriate drug for the transport team to administer in this case.
The client has acute kidney injury (AKI). Which assessment finding requires immediate intervention?
- A. Urine output of 50 ml in the last hour.
- B. Serum potassium of 6.2 mEq/L.
- C. Blood pressure of 150/90 mm Hg.
- D. Serum creatinine of 2.5 mg/dL.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium of 6.2 mEq/L. Hyperkalemia is a life-threatening condition in AKI. High potassium levels can lead to cardiac arrhythmias and must be addressed immediately. Choice A is concerning but not as critical as hyperkalemia. Choice C, elevated blood pressure, needs monitoring but does not require immediate intervention. Choice D, elevated serum creatinine, indicates kidney dysfunction but does not pose an immediate threat compared to hyperkalemia.
A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority?
- A. Apply a hypothermia unit to stabilize core temperature.
- B. Increase the client's IV fluid rate to 200 ml/hr.
- C. Call the hospital chaplain to counsel the family.
- D. Draw blood cultures x3 to detect infection.
Correct Answer: B
Rationale: The correct answer is B: Increase the client's IV fluid rate to 200 ml/hr. The client's vital signs indicate hypotension, tachycardia, decreased urine output, and cool skin, suggesting hypovolemic shock. Increasing IV fluid rate will help to restore intravascular volume and improve perfusion to vital organs. This is the highest priority as it addresses the immediate physiological need for circulatory support.
Choice A is incorrect because hypothermia is not indicated based on the client's presentation. Choice C is incorrect as it does not address the client's urgent physiological needs. Choice D is incorrect as drawing blood cultures, while important, is not the most immediate priority in this situation.