Nokea
The nurse is caring for a client taking prescribed captopril. Which abnormal laboratory value should the nurse prioritize when notifying the healthcare provider?
- A. Serum creatinine 1.3 mg/dL (114.92 μmol/L) [Male: 0.6-1.2 mg/dL, Female: 0.5-1.1 mg/dL, Male 49-93 μmol/L, Female 22-75 μmol/L]
- B. Serum potassium 5.2 mEq/L (mmol/L) [3.5-5 mEq/L (mmol/L)]
- C. Serum phosphorus 4.6 (1.48 mmol/L) [2.5-4.5 mg/dL, 0.81-1.58 mmol/L]
- D. Blood glucose 135 mg/dL (7.5 mmol/L) [70-110 mg/dL, 4-6 mmol/L]
Correct Answer: B
Rationale: Hyperkalemia (potassium 5.2 mEq/L, B) is a priority with captopril, an ACE inhibitor, as it can cause life-threatening arrhythmias. Creatinine (A) and phosphorus (C) are slightly elevated but less urgent. Glucose (D) is elevated but not critical in this context.
You may also like to solve these questions
The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who
- A. had an adrenalectomy 24 hours ago and has become restless with the most recent blood pressure (BP) of 98/60 mm Hg.
- B. has a continuous infusion of heparin for the treatment of a pulmonary embolism (PE) and has an activated partial thromboplastin time (aPTT) of 70 seconds (normal 30-40 seconds).
- C. is receiving mechanical ventilation to treat hospital-acquired pneumonia (HAP) and was last suctioned via the endotracheal (ET) tube two hours ago.
- D. has a newly placed chest tube for hemothorax and has had 45 mL of bright red drainage in the past hour.
Correct Answer: A
Rationale: Restlessness and BP of 98/60 mm Hg 24 hours post-adrenalectomy (A) suggest possible adrenal crisis or hypovolemia, a life-threatening emergency requiring immediate follow-up. Elevated aPTT on heparin (B) indicates therapeutic anticoagulation, recent suctioning (C) is routine, and 45 mL chest tube drainage (D) is within normal limits, all less urgent.
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks should the nurse assign to the UAP?
- A. Obtain a tympanic temperature for a client who received naproxen one hour ago
- B. Record and empty a closed suction drain for a client recovering from a mastectomy
- C. Assist a client in picking out low-sodium foods on their lunch menu
- D. Transport a client receiving an infusion of dopamine to the intensive care unit
Correct Answer: A
Rationale: Obtaining a tympanic temperature (A) is a routine task within UAP scope. Recording drain output (B), dietary education (C), and transporting a client on dopamine (D) require nursing judgment or monitoring.
The nurse is caring for assigned clients. The nurse should first assess the client
- A. with a right femur fracture who reports pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- B. with chronic obstructive pulmonary disease (COPD) who is reporting shortness of breath while ambulating in the hallway.
- C. with a history of T6 spinal injury 6 months ago, now reports a severe headache and is diaphoretic.
- D. one day postoperative from an open cholecystectomy with green drainage from the t-tube.
Correct Answer: C
Rationale: Severe headache and diaphoresis in a T6 spinal injury (C) suggest autonomic dysreflexia, a life-threatening emergency. COPD shortness of breath (B), femur fracture pain (A), and t-tube drainage (D) are less urgent.
The nurse is caring for assigned clients. The nurse should initially assess the client who
- A. is recovering from a femoral angioplasty and reports their foot is falling asleep.
- B. has diabetes mellitus and refused their prescribed glargine insulin.
- C. received alteplase three hours ago for a stroke and has a Glasgow Coma Scale of 14.
- D. had a T6 spinal cord injury and has not had a bowel movement since yesterday.
Correct Answer: A
Rationale: Numbness post-femoral angioplasty (A) suggests vascular compromise, such as occlusion, requiring immediate assessment. Insulin refusal (B), stable GCS post-alteplase (C), and constipation in spinal injury (D) are less urgent.
The nurse is caring for a client experiencing an acute episode of vertigo. Which of the following actions would be a priority for the nurse?
- A. instruct the client to avoid sudden, jerky movements.
- B. Request a prescription for an antihistamine.
- C. Raise the upper side rails of the client's bed.
- D. Assess the client for nausea and vomiting.
Correct Answer: C
Rationale: Raising side rails (C) is the priority in acute vertigo to prevent falls due to dizziness, ensuring immediate safety. Avoiding movements (A), antihistamine (B), and nausea assessment (D) are important but secondary to fall prevention.