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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale:

Provide a safe and calm environment for the client during a panic attack. Creating a safe and calm environment is crucial during a panic attack. It can help the client feel more secure and reduce the intensity and duration of the panic attack.

Choice B rationale:

Use therapeutic communication skills to establish rapport and trust with the client. Therapeutic communication is essential for clients with panic disorder. It helps establish a trusting relationship between the nurse and the client, which is crucial for effective treatment and support.

Choice C rationale:

Educate the client about panic disorder and its treatment options. Educating the client about their condition and available treatment options empowers them to make informed decisions about their care. It also reduces anxiety and fear associated with the disorder.

Choice D rationale:

Encourage the client to participate in cognitive-behavioral therapy (CBT). Cognitive-behavioral therapy is a well-established and effective treatment for panic disorder. Encouraging the client to participate in CBT can help them develop coping strategies and manage their symptoms.

Choice E rationale:

Refer the client to self-help groups for peer support and education. Self-help groups can provide valuable peer support and education to individuals with panic disorder. Being part of such a group can reduce feelings of isolation and provide practical advice for managing the condition.

A. Procure platelet products from the blood bank. B. Titrate oxygen to the prescribed parameters. C. Monitor an intravenous infusion rate on an established schedule. D. Insert a urinary catheter for an uncomplicated client.

Correct Answer is C

Explanation

Choice A rationale:

Procure platelet products from the blood bank. Rationale: Procuring platelet products from the blood bank is a specialized task that requires specific training and authorization. It should be performed by licensed healthcare providers, such as nurses or physicians, rather than unlicensed assistive personnel (UAP).

Choice B rationale:

Titrate oxygen to the prescribed parameters. Rationale: Titrating oxygen to prescribed parameters requires clinical judgment and assessment skills, which are beyond the scope of practice for UAP. This task should be performed by licensed nurses or respiratory therapists.

Choice C rationale:

Monitor an intravenous infusion rate on an established schedule. Rationale: This is the correct answer. UAP can be trained to monitor intravenous (IV) infusion rates on an established schedule for clients who do not require complex adjustments. It is within their scope of practice to ensure that the IV is running at the prescribed rate and to report any abnormalities or concerns to the nursing staff.

Choice D rationale:

Insert a urinary catheter for an uncomplicated client. Rationale: Inserting a urinary catheter is a specialized nursing procedure that should only be performed by licensed nurses or healthcare providers. It is not within the scope of practice for UAP, even for uncomplicated cases.

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Naxlex Comprehensive Predictor Exams

A nurse is providing interventions for a client with panic disorder. Which interventions should the nurse include in the plan of care? (Select all that apply).

Correct Answer is ["A","B","C","D","E"]

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Patient Data. Exhibits Which order would the nurse question? Select all that apply.

A nurse is planning recreational activities for a group of patients who are receiving rehabilitation and restorative care. Which of the following factors should the nurse consider when selecting appropriate activities? (Select all that apply.).

A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?