Nokea
The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?
- A. Frequency of laxative use for chronic constipation
- B. Dietary intake of magnesium-rich foods
- C. Use of magnesium-containing supplements
- D. History of alcohol use
Correct Answer: A
Rationale: The correct answer is A. Frequent use of magnesium-containing laxatives can lead to hypermagnesemia, particularly in elderly clients. Option B, dietary intake of magnesium-rich foods, may contribute to elevated serum magnesium levels but is less likely the cause in this scenario. Option C, the use of magnesium-containing supplements, can also contribute to hypermagnesemia but is not as common in elderly clients without a history of using such supplements. Option D, history of alcohol use, is less relevant to the development of elevated serum magnesium levels compared to laxative use for chronic constipation.
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A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should be reported to the healthcare provider before the procedure?
- A. Serum creatinine of 2.5 mg/dL
- B. Serum potassium of 6.5 mEq/L
- C. Serum calcium of 8 mg/dL
- D. Serum bicarbonate of 24 mEq/L
Correct Answer: B
Rationale: The correct answer is B. A serum potassium level of 6.5 mEq/L is dangerously high and should be reported before hemodialysis to prevent cardiac complications. High potassium levels can lead to life-threatening arrhythmias. Serum creatinine (Choice A) is elevated in renal dysfunction but not the most critical value to report before hemodialysis. Serum calcium (Choice C) and serum bicarbonate (Choice D) levels are within normal limits and are not immediate concerns before hemodialysis.
An adult male who lives alone is brought to the Emergency Department by his daughter who found him unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and ventilated. Which nursing intervention has the highest priority?
- A. Notify the client's minister of his condition.
- B. Determine if the client has an executed living will.
- C. Provide the family with information about palliative care.
- D. Discuss the possibility of organ donation with the family.
Correct Answer: B
Rationale: Verifying whether the client has an executed living will is crucial to ensuring that his treatment preferences are followed. In this critical situation, knowing the client's wishes regarding medical interventions is paramount. Options A, C, and D are not the highest priority as they do not directly address the immediate need to determine the client's treatment preferences.
A client with chronic kidney disease (CKD) is scheduled for a renal biopsy. Which laboratory value should the nurse review before the procedure?
- A. Serum potassium
- B. Serum creatinine
- C. Hemoglobin
- D. White blood cell count
Correct Answer: B
Rationale: Before a renal biopsy, the nurse should review the serum creatinine level. Serum creatinine is a key indicator of kidney function. In clients with chronic kidney disease (CKD), monitoring creatinine levels is crucial as elevated levels may indicate worsening kidney function, which could impact the safety and outcome of the biopsy. Hemoglobin (choice C) is important for assessing oxygen-carrying capacity but is not directly related to the kidney biopsy procedure. Serum potassium (choice A) is important to monitor in CKD but is not specifically crucial before a renal biopsy. White blood cell count (choice D) is more relevant for assessing infection or inflammation, which is not the primary concern before a renal biopsy.
The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement?
- A. Talk directly to the adolescent while providing care
- B. Maintain silence during care to avoid overstimulation
- C. Play soothing music in the background
- D. Limit visitors to immediate family only
Correct Answer: A
Rationale: Talking directly to the adolescent is the most appropriate intervention in this scenario. It helps maintain a sense of connection and respect, even if the response is not evident. Maintaining silence may lead to isolation and hinder any potential communication attempts. Playing soothing music may not provide the personal interaction needed for connection. Limiting visitors to immediate family only may deprive the patient of diverse interactions that could be beneficial for their emotional well-being.
In a client with heart failure receiving digoxin (Lanoxin) and furosemide (Lasix), which laboratory value requires immediate intervention?
- A. Serum potassium of 4.0 mEq/L
- B. Blood glucose of 200 mg/dl
- C. Serum creatinine of 1.5 mg/dl
- D. Serum potassium of 3.2 mEq/L
Correct Answer: D
Rationale: A serum potassium level of 3.2 mEq/L is low and concerning in a client receiving digoxin and furosemide. Hypokalemia increases the risk of digoxin toxicity, leading to life-threatening arrhythmias. Therefore, immediate intervention is necessary to prevent complications. The other options, serum potassium of 4.0 mEq/L, blood glucose of 200 mg/dl, and serum creatinine of 1.5 mg/dl, are within normal limits and do not pose immediate risks to the client in this scenario.