Nokea
The client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value is most concerning?
- A. Serum potassium of 6.0 mEq/L
- B. Serum creatinine of 2.5 mg/dL
- C. Serum calcium of 8.0 mg/dL
- D. Hemoglobin of 10 g/dL
Correct Answer: A
Rationale: A serum potassium level of 6.0 mEq/L is most concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, which can lead to serious cardiac complications such as arrhythmias and cardiac arrest. Immediate intervention is required to lower potassium levels.
Choice B, serum creatinine of 2.5 mg/dL, is elevated but expected in ESRD due to impaired kidney function. Choice C, serum calcium of 8.0 mg/dL, is within the normal range and not typically a priority in this situation. Choice D, hemoglobin of 10 g/dL, is slightly low but not an immediate concern for a client scheduled for hemodialysis unless significantly lower and causing severe symptoms.
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A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed due to early morning stiffness. Which intervention should the nurse implement?
- A. Assign a UAP to assist the client with a warm shower early in the morning.
- B. Administer anti-inflammatory medication before the procedure.
- C. Encourage the client to perform range-of-motion exercises.
- D. Reschedule the procedure for later in the day.
Correct Answer: A
Rationale: A warm shower can help alleviate stiffness, allowing the client to be more comfortable and mobile before the procedure. This intervention promotes increased comfort and mobility, which may help the client proceed with the procedure later in the day. Administering anti-inflammatory medication (Choice B) may be helpful but may take time to be effective, while range-of-motion exercises (Choice C) may be challenging for the client due to stiffness. Rescheduling the procedure (Choice D) does not address the immediate need to alleviate stiffness.
The nurse is caring for a client with acute pancreatitis who is receiving total parenteral nutrition (TPN). Which laboratory value should be monitored closely?
- A. Serum calcium
- B. Serum triglycerides
- C. Serum glucose
- D. Serum triglycerides
Correct Answer: B
Rationale: Serum triglycerides should be monitored closely in a client receiving TPN as they may indicate hyperlipidemia, which is a potential complication of TPN. Monitoring serum triglycerides is essential to prevent complications such as hypertriglyceridemia. Serum calcium and glucose levels are also important to monitor in clients receiving TPN, but in this scenario, serum triglycerides take priority due to the risk of hyperlipidemia.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct Answer: C
Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD and pneumonia, the use of accessory muscles indicates increased work of breathing and may signal respiratory failure. Immediate intervention is necessary to prevent further deterioration of the respiratory status. Choice A, an oxygen saturation of 90%, though low, may not require immediate intervention as it is above the typical threshold for initiating supplemental oxygen. Choice B, a respiratory rate of 24 breaths per minute, falls within the normal range for an adult and may not be an immediate cause for concern. Choice D, inspiratory crackles, are indicative of fluid in the lungs but may not require immediate intervention unless accompanied by other concerning signs like decreased oxygen saturation or increased respiratory distress.
Which needle should the nurse use to administer intravenous fluids (IV) via a client's implanted port?
- A. The one with the clamp and no needle
- B. A butterfly needle
- C. A non-coring (Huber) needle
- D. A standard hypodermic needle
Correct Answer: C
Rationale: The correct needle to use for administering intravenous fluids via an implanted port is a non-coring (Huber) needle. This type of needle is specifically designed to access implanted ports without coring the septum, which helps prevent damage. Choice A, the one with the clamp and no needle, is incorrect as it does not describe a needle suitable for accessing an implanted port. Choice B, a butterfly needle, is not typically used for accessing implanted ports. Choice D, a standard hypodermic needle, is not ideal for accessing ports as it can damage the septum.
A client with chronic liver disease is admitted with ascites and jaundice. Which assessment finding is most concerning?
- A. Enlarged spleen
- B. Increased abdominal girth
- C. Yellowing of the skin
- D. Confusion and altered mental status
Correct Answer: D
Rationale: Confusion and altered mental status are concerning in a client with chronic liver disease, as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Enlarged spleen (choice A) can be a common finding in liver disease due to portal hypertension but may not be as acute as hepatic encephalopathy. Increased abdominal girth (choice B) is typically seen in ascites, which is already present in this client. Yellowing of the skin (choice C) is a manifestation of jaundice, also a known symptom in liver disease but not as acute as confusion and altered mental status.