36. A nurse is caring for a client.
Exhibits
Which of the following findings at 1015 requires further action?

(Select all that apply.)

Low back pain

Urine color

Blood pressure

Respiratory rate

Answer and Explanation

Correct Answer : C,D

A.   While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B.   Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C.   A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D.   An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E.   The client’s oxygen saturation is 95% on room air which is normal.

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Correct Answer is A

Explanation

Rationale:
A. Furosemide is a loop diuretic that helps to lower potassium levels, making it appropriate for a client with hyperkalemia (potassium level of 5.3 mEq/L).
B. Potassium iodide would further increase potassium levels, which is contraindicated in this situation.
C. Digoxin does not directly affect potassium levels and could be dangerous in the context of hyperkalemia.
D. Lisinopril is an ACE inhibitor that can increase potassium levels, which would not be appropriate for this client.

A. Hepatitis B. Renal stones C. Hip fracture D. Pancreatitis

Correct Answer is B

Explanation

A. Hepatitis is not a known adverse effect of calcium supplementation.
B. Renal stones (kidney stones) are a potential adverse effect of excessive calcium intake, and flank pain is a common symptom of kidney stones.
C. Hip fractures are a concern with osteoporosis but not an adverse effect of calcium supplementation.
D. Pancreatitis is not a known adverse effect of calcium supplementation.

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36. A nurse is caring for a client. Exhibits Which of the following findings at 1015 requires further action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client whose serum potassium level is 5.3 mEq/L. Which of the following scheduled medications should the nurse plan to administer?

Correct Answer is A

Explanation

A nurse is caring for a client who has osteoporosis and takes a daily calcium supplement. Which of the following adverse effects of calcium should the nurse suspect when the client reports having flank pain?

Correct Answer is B

Explanation

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.)

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36. A nurse is caring for a client.
Exhibits
Which of the following findings at 1015 requires further action?