Nokea
The nurse is caring for a client with hypokalemia scheduled to receive the prescribed 20 mEq of intravenous (IV) potassium. Which client assessment requires notification of the primary healthcare provider (PHCP)?
- A. Oliguria
- B. Abdominal distention
- C. Muscle weakness
- D. Weak peripheral pulses
Correct Answer: A
Rationale: Oliguria indicates poor renal function, which can lead to potassium accumulation, requiring PHCP notification before IV potassium administration.
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The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 5 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.
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)]
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.
0850: Verbal order was received from physician to insert indwelling urethral catheter.
0910: Urinary catheter inserted with sterile technique. 40 mL of dark yellow urine returned.
Orders
• admit to intensive care unit
• nephrology consultation
• oncology consultation
• fluid restriction - 1 liter daily
• daily weight
• strict intake and output
• 250 mL of 3% saline at 75 mL/hr
• tolvaptan 15 mg PO daily - first dose now
• neurological assessments every two hours
The nurse reviews the orders and prepares to administer the first dose of prescribed tolvaptan. Complete the following sentences by choosing from the lists of options. Prior to administering the first dose of this medication, the nurse should obtain an order to review the client's baseline.............. as.......................... is a serious adverse effect of this medication? Osmotic demyelination syndrome is another serious adverse reaction to this medication and requires monitoring of the client's.................
- A. liver enzymes
- B. thyroid toxicity
- C. liver injury
- D. myocardial infarction
- E. urinary output.
- F. Glasgow coma scale.
- G. blood pressure.
Correct Answer: A,F
Rationale: Tolvaptan can cause liver injury, requiring baseline liver enzyme monitoring. Osmotic demyelination syndrome requires neurological monitoring via Glasgow Coma Scale.
The nurse is reviewing the client's laboratory data. Which current prescription should the nurse clarify with the primary healthcare provider (PHCP)?
- A. hydrochlorothiazide
- B. lisinopril
- C. naproxen
- D. tamsulosin
Correct Answer: C
Rationale: Naproxen can impair renal function, requiring clarification in clients with kidney issues.
The nurse is caring for a client who is severely hypernatremic. The nurse should prioritize assessing the client's
- A. cardiovascular status.
- B. genitourinary status.
- C. neurological status.
- D. gastrointestinal status.
Correct Answer: C
Rationale: Hypernatremia affects neurological status due to cellular dehydration, causing confusion, seizures, or coma, requiring priority assessment.
The nurse is caring for a client who was newly prescribed warfarin. Which medication on the client's medication list requires follow-up with the primary healthcare provider (PHCP)?
- A. Loratadine
- B. Saw Palmetto
- C. Furosemide
- D. Pantoprazole
Correct Answer: B
Rationale: Saw Palmetto can interact with warfarin by potentially increasing bleeding risk due to its antiplatelet effects, requiring follow-up with the PHCP. Loratadine (A), Furosemide (C), and Pantoprazole (D) have minimal interactions with warfarin.
The nurse is caring for a 68-year-old individual in the emergency department who had been on the bathroom floor for about 10 hours after a fall. While performing straight catheterization, the nurse notes that the urine output reaches 800 mL and continues to flow heavily. What action should the nurse take, and what is the rationale for this action?
- A. Drain the client's bladder entirely and place a small amount in a urine specimen cup. This client needs a urine sample to check for rhabdomyolysis.
- B. Continue draining the bladder fully, then place a Foley catheter to monitor for sufficient urine output.
- C. Stop draining the client's bladder because the client is at risk for developing bladder spasms.
- D. Stop draining the client's bladder to prevent the risk of urinary tract infection (UTI) and notify the primary healthcare provider (PHCP) for further instructions.
Correct Answer: A
Rationale: Prolonged immobility increases rhabdomyolysis risk, requiring a urine sample to check for myoglobin.