The nurse is assessing a client who was just diagnosed with...

The nurse is reviewing labs for a client with a serum potassium level of 3.3 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. The nurse should take which essential action based on this laboratory result?

A. Educate the client on potassium-rich foods
B. Implement continuous telemetry monitoring
C. Obtain an order for calcium gluconate
D. Assess the client's neurological status

Correct Answer: A

Rationale: Hypokalemia (low potassium) requires dietary education to increase potassium intake, as it does not typically necessitate telemetry or calcium.

The nurse reviews a client's laboratory data. Which laboratory data requires follow-up?

A. Sodium
B. Potassium
C. Calcium
D. BUN
E. Creatinine

Correct Answer: B,C,D,E

Rationale: Abnormal potassium, calcium, BUN, and creatinine require follow-up due to potential renal or electrolyte imbalances.

The nurse is caring for an assigned client. Which prescription requires clarification based on the laboratory data? See the exhibit. Select all that apply. Prescribed Medications: vancomycin 1-gram IVPB daily, furosemide 40 mg PO daily, 500 mL of 0.9% sodium chloride bolus x 1 dose, diltiazem XR 120 mg PO daily, Ketorolac 15 mg IV push every eight hours PRN pain. Laboratory Results: Sodium 145 mEq/L (145 mmol/L), Potassium 3.7 mEq/L (3.7 mmol/L), Calcium 9.3 mg/dL (2.32 mmol/L), BUN 25 mg/dL (8.93 mmol/L), Creatinine 2.1 mg/dL (185.64 umol/L)

A. vancomycin 1-gram IVPB Daily
B. furosemide 40 mg PO Daily
C. 500 ml of 0.9% Saline IV Bolus x 1
D. diltiazem XR 120 mg PO Daily
E. ketorolac 15 mg IV Q 8 hours

Correct Answer: A,E

Rationale: Vancomycin (A) and Ketorolac (E) require clarification due to the elevated creatinine (2.1 mg/dL), indicating impaired renal function, which can increase the risk of toxicity for both drugs. Furosemide (B), saline bolus (C), and diltiazem (D) are not contraindicated with the given lab results.

The nurse is caring for a client with a kidney injury with a serum potassium level of 6.1 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. Which of the following actions is a priority?

A. Obtain a prescription for a diuretic to increase urine output
B. Check the client's sodium level
C. Place the client on a cardiac monitor
D. Encourage oral fluid intake

Correct Answer: C

Rationale: Hyperkalemia (6.1 mEq/L) poses a risk for cardiac dysrhythmias, making cardiac monitoring a priority.

The following scenario applies to the next 6 items.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 3 of 6
History and Physical
A 57-year-old male client with stage three small cell lung cancer. The client had suddenly become disoriented and did not recognize his family members and relatives. He reports severe lower extremity weakness and has had three episodes of diarrhea in the past four hours. The client is undergoing 6 cycles of chemotherapy with cisplatin and etoposide. He is currently taking a 14-day course of 15 mg of prednisone. He is on his third day of steroid treatment. He has a medical history of dyslipidemia and advanced chronic obstructive pulmonary disease.

Nurses' Notes
0759: Client is completely disoriented and required maximum assistance to the stretcher because of unsteady gait. Lung sounds clear bilaterally. Alopecia noted. Skin is warm and dry and normal for ethnicity. Peripheral pulses 2+. No skin tenting. Hyperactive bowel sounds in all quadrants. 20-gauge peripheral vascular access device placed in the left antecubital space. T 97.8° F (36.6° C) P 88 RR 21 BP 123/68 Pulse oximetry reading 91% on room air.

Laboratory Results
• Hemoglobin 14 g/dL [14-18 g/dL (140–180 g/L)]
• Hematocrit 42% (0.42) [42-52% (0.42-0.52)]
• White Blood Cell 11,000 mm3 [5-10 mm3]
• Platelet Count 140,000 mm3 [150-400 mm3 (150–400 × 109/L)]
• Glucose 139 mg/dL (7.72 mmol/L) [70–110 mg/dL (4-6 mmol/L)]
• Sodium 116 mEq/L [136–145 mEq/L (mmol/L)]
• Potassium 3.3 mEq/L [3.5–5.0 mEq/L (mmol/L)]
• Creatinine 0.7 mg/dL (61.88 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
• Blood Urea Nitrogen 8 mg/dL (2.86 mmol/L) [10–20 mg/dL (3.6–7.1 mmol/L)]
• Serum Osmolality 277 mOsm/kg [285-295 mOsm/kg (285–295 mmol/kg)]

The client is demonstrating manifestations consistent with......... due to.......

A. Cushing's syndrome
B. diabetes insipidus
C. syndrome of inappropriate antidiuretic hormone
D. advanced chronic obstructive pulmonary disease.
E. small cell lung cancer.
F. corticosteroid usage.

Correct Answer: C,E

Rationale: SIADH, often caused by small cell lung cancer, leads to hyponatremia and neurological symptoms like disorientation.

Urinary Elimination NCLEX RN Questions Related

Correct Answer: A,C,E