A client with intestinal obstruction has a nasogastric tube to low intermittent suction and is receiving an intravenous (IV) infusion of lactated Ringer's at 100 mL/hour.
Which finding is most important for the nurse to report to the healthcare provider? Reference Range: Potassium (3.5 to 5 mEq/L (3.5 to 5 mmol/L).

24-hour intake at the current infusion rate.

Serum potassium level of 3.1 mEq/L (3.1 mmol/L).

Gastric output of 900 mL in the last 24 hours.

Increased blood urea nitrogen (BUN).

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Reporting the 24-hour intake at the current infusion rate is not the most important finding to report to the healthcare provider in this case. It is essential to monitor intake and output, but a single report of the 24-hour intake is not as critical as other findings.

Choice B rationale:

Reporting a serum potassium level of 3.1 mEq/L (3.1 mmol/L) is the most important finding to report to the healthcare provider. The patient's potassium level is below the normal range, indicating hypokalemia. Hypokalemia can have serious cardiac and neuromuscular effects, including arrhythmias and muscle weakness. Prompt intervention, such as potassium supplementation or adjustment of IV fluids, is necessary to address this potentially life-threatening condition.

Choice C rationale:

Reporting a gastric output of 900 mL in the last 24 hours is significant and should be reported to the healthcare provider, but it is not as urgent as the low potassium level. Gastric output should be monitored to assess for signs of improvement or worsening, but hypokalemia takes precedence due to its immediate health risks.

Choice D rationale:

Reporting an increased blood urea nitrogen (BUN) is important for the overall assessment of the patient's renal function but is not the most critical finding in this scenario. The low potassium level is a more immediate concern and requires immediate attention.

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Correct Answer is B

Explanation

Choice A rationale:

Assisting in discharging stable clients to home is not the most appropriate assignment when a mass casualty event has occurred. During such events, resources are needed for critically injured patients, and stable clients can typically be discharged by non-emergency staff.

Choice B rationale:

Determining the acuity and number of casualties arriving at the facility is the most appropriate assignment during a mass casualty event. This information is critical for allocating resources and providing the necessary level of care to those affected.

Choice C rationale:

Delegating tasks to emergency healthcare specialists may be necessary, but it is not the initial assignment for the nurse working on a medical-surgical unit. Assessing the situation and determining the acuity of incoming casualties take precedence.

Choice D rationale:

Providing informational updates to members of the media is not the role of a nurse during a mass casualty event. This task should be handled by hospital public relations or designated spokespersons to ensure accurate and controlled information dissemination.

A. A bottle is generally much better than using a pacifier. B. The bottle will assist in preventing thumb sucking. C. Prolonged bottle use can increase the risk for cavities. D. Using milk rather than juice helps to avoid tooth decay.

Correct Answer is C

Explanation

Choice A rationale:

A bottle is generally much better than using a pacifier. This statement is not accurate. Prolonged bottle use, especially with sugary liquids like milk, can have adverse effects on a child's dental health. It can lead to an increased risk of cavities, similar to prolonged pacifier use.

Choice B rationale:

The bottle will assist in preventing thumb sucking. This statement is incorrect. While a bottle may provide comfort to a child, it does not prevent thumb sucking. Thumb sucking is a separate behavior that may also have dental implications if it persists beyond a certain age.

Choice C rationale:

Prolonged bottle use can increase the risk for cavities. This response is correct. Prolonged bottle use, especially with milk or sugary beverages, can expose the child's teeth to prolonged contact with sugars, increasing the risk of cavities. It's important for the nurse to educate the mother about the potential dental risks associated with extended bottle use.

Choice D rationale:

Using milk rather than juice helps to avoid tooth decay. While milk is generally considered a healthier choice than juice, the key issue in this scenario is the prolonged use of the bottle, regardless of its content. Prolonged bottle use with any liquid, including milk, can still increase the risk of cavities.

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Naxlex Comprehensive Predictor Exams

A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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