A client’s bloodwork indicates that he has severe hypokalemia.
What is a priority nursing intervention?

Place the client on a cardiac monitor.

Administer a laxative as ordered.

Place the client on seizure precautions.

Restrict high potassium foods.

Answer and Explanation

The Correct Answer is A

This is because hypokalemia (low potassium level in the blood) can cause abnormal heart rhythms (arrhythmia) that can be life-threatening and require urgent medical attention. A cardiac monitor can help detect and treat any arrhythmia that may occur.

Choice B is wrong because administering a laxative can worsen hypokalemia by causing more potassium loss through the digestive tract. Laxative use is one of the possible causes of hypokalemia.

Choice C is wrong because placing the client on seizure precautions is not a priority intervention for hypokalemia. Seizures are not a common symptom of hypokalemia, although muscle weakness and cramps may occur.

Choice D is wrong because restricting high potassium foods is not a priority intervention for hypokalemia. In fact, increasing potassium intake through foods or supplements may be helpful in less serious cases of hypokalemia. However, this should be done according to the doctor’s recommendation and with careful monitoring of blood potassium levels.

Normal blood potassium levels for an adult range from 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than 2.5 mmol/L) can be life threatening.

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Correct Answer is A

Explanation

Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be the risk for deficient fluid volume.

Choice B. Risk for infection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.

Choice C. Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.

Choice D. Pain is correct because appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.

A. A client who has a family history of breast cancer is scheduled for a mammogram. B. A client who has heart failure is scheduled for an echocardiogram. C. A client who is asymptomatic is not scheduled for a series of tests. D. A client is scheduled to receive an influenza vaccination.

Correct Answer is A

Explanation

This is an example of secondary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complications. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.

This is an example of tertiary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complication. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

Choice C is wrong because it is not an example of any level of prevention.

A client who is asymptomatic is not scheduled for a series of tests because there is no indication of any disease or risk factor.

Choice D is wrong because it is an example of primary prevention, which is the action taken to prevent the development of disease.

A client who is scheduled to receive an influenza vaccination is protected from getting infected by the virus and developing flu-related complications.

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A client’s bloodwork indicates that he has severe hypokalemia. What is a priority nursing intervention?

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Naxlex Comprehensive Predictor Exams

Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

Correct Answer is A

Explanation

A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention?

Correct Answer is A

Explanation

The nurse knows that infants have a high risk of hypothermia due to decreased brown fat, immature skin, and poorly developed thermoregulatory mechanism. Which nursing intervention is done to prevent heat loss by conduction?

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

An elderly client is hospitalized for the first time. Which of the following actions ensures the safety of the client? (Select all that apply).

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

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A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse’s priority?

A client’s bloodwork indicates that he has severe hypokalemia.
What is a priority nursing intervention?