A client reports a 2-day history of fever, vomiting, and diarrhea. The healthcare provider prescribes serum electrolyte levels to be obtained.

Reference Range:

Potassium (K+): 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)

Sodium (Na+): 136 to 145 mEq/L (136 to 145 mmol/L)

Which laboratory results should the nurse expect?

Serum potassium: 3.5 mEq/L (3.5 mmol/L), serum sodium: 142 mEq/L (142 mmol/L)

Serum potassium: 4.5 mEq/L (4.5 mmol/L), serum sodium: 140 mEq/L (140 mmol/L)

Serum potassium: 5.0 mEq/L (5.0 mmol/L), serum sodium: 138 mEq/L (138 mmol/L)

Serum potassium: 3.0 mEq/L (3.0 mmol/L), serum sodium: 149 mEq/L (149 mmol/L)

Answer and Explanation

The Correct Answer is D

Choice A rationale: Potassium 3.5 mEq/L and sodium 142 mEq/L are within normal ranges, not expected after vomiting and diarrhea which typically cause hypokalemia and hypernatremia due to fluid loss.

Choice B rationale: Potassium 4.5 mEq/L and sodium 140 mEq/L remain normal, not consistent with dehydration and gastrointestinal fluid loss, which usually lower potassium and elevate sodium concentration.

Choice C rationale: Potassium 5.0 mEq/L and sodium 138 mEq/L are normal values, not typical after prolonged vomiting and diarrhea, where potassium decreases and sodium increases due to water deficit.

Choice D rationale: Potassium 3.0 mEq/L indicates hypokalemia from gastrointestinal losses, and sodium 149 mEq/L indicates hypernatremia from dehydration, both expected findings after vomiting and diarrhea.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: While heart rate is important, it is not the most immediate concern when a client shows signs of cyanosis.

Choice B reason: Blood pressure is a critical vital sign but does not directly address the issue of oxygenation, which is suggested by cyanosis.

Choice C reason: Temperature is less relevant to the immediate assessment of cyanosis, which is often related to oxygenation issues.

Choice D reason: Respiratory rate should be assessed first as cyanosis is a sign of potential hypoxia, and the respiratory rate can provide immediate information about the client's breathing and oxygenation status.

A. Assess for sources of pain other than the surgical site. B. Change to a behavioral pain scale. C. Give a dose of 2.5 mg of morphine. D. Refer to social work for drug-seeking behavior. E. Bring an opioid reversal agent to the bedside. F. Lead the client in guided imagery. G. Consult with the surgeon about the pain level. H. Helping the client walk around the room.

Correct Answer is ["A","C","G","H"]

Explanation

Choice A reason:
The increase in heart rate from 78 to 118 beats per minute, along with the increase in pain rating from 3 to 8, suggests that the client may be experiencing pain from a source other than the surgical site. It is important to assess for other potential sources of pain to ensure comprehensive pain management.
Choice B reason:
Changing to a behavioral pain scale is not indicated in this scenario. The numerical pain scale is a standard and effective method for assessing pain levels, and there is no indication that the client has difficulty communicating her pain using this scale.
Choice C reason:
Given that the client's pain rating increased to 8, which is above the threshold of 4 on the pain scale, administering a dose of 2.5 mg of morphine as per the orders is appropriate to manage her pain.
Choice D reason:
Referring to social work for drug-seeking behavior is not supported by the information provided. The client's increased pain rating and heart rate suggest a legitimate need for pain management rather than drug-seeking behavior.
Choice E reason:
Bringing an opioid reversal agent to the bedside is not indicated unless there is a concern for opioid overdose, which is not suggested by the information provided.
Choice F reason:
While guided imagery can be a helpful adjunct for pain management, it is not the primary intervention needed at this time given the client's significant increase in pain and heart rate.
Choice G reason:
Consulting with the surgeon about the client's increased pain level is important to rule out any complications from the surgery and to discuss further pain management strategies.
Choice H reason:
Assisting the client to walk around the room may help in pain management and is part of the postoperative care plan to increase walking distance. However, it should be done cautiously considering the client's current pain level.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

Correct Answer is D

Explanation

Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

Correct Answer is ["A","C","G","H"]

Explanation

The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

Exhibits What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.