A nurse has just received the morning change of shift report for four clients. Which of the following clients has the highest priority need?
A client who has a serum potassium level of 5 mEq/L and is scheduled for dialysis in the afternoon.
A client who returned 1 hour ago from lithotripsy and is reporting nausea.
A client who had a total abdominal hysterectomy 2 days ago and is reporting a pain level of 3 on a scale of 0 to 10.
A client who has an indwelling urinary catheter and has a total urine output of 80 mL over the past 8 hours.
The Correct Answer is D
Choice A reason: While a serum potassium level of 5 mEq/L is at the higher end of the normal range, the client is scheduled for dialysis, which should address the issue.
Choice B reason: Nausea after lithotripsy is a concern, but it may not be as urgent as other conditions.
Choice C reason: A pain level of 3 is manageable and not the highest priority compared to other more acute needs.
Choice D reason: A urine output of 80 mL over 8 hours is significantly low and could indicate acute kidney injury or urinary retention, which requires immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Placing the head of the bed at a 30° angle is the priority action to reduce the risk of aspiration during the feeding.
Choice B reason: Documenting the client's response is important but not the priority action before starting the feeding.
Choice C reason: Wiping the top of the feeding container with alcohol is a standard practice for infection control but is secondary to positioning the client properly.
Choice D reason: Rinsing the feeding bag with water after the feeding is complete is a cleaning procedure and not a priority before starting the feeding.
Correct Answer is B
Explanation
Choice A reason: Remaining upright for 30 minutes after eating may help with digestion, but it is not specific to the management of dumping syndrome.
Choice B reason: Eliminating simple sugars is crucial in the management of dumping syndrome as they can cause rapid gastric emptying, leading to symptoms.
Choice C reason: Eating three large meals per day is not recommended for dumping syndrome; smaller, more frequent meals are advised to prevent symptoms.
Choice D reason: Drinking water with meals can exacerbate symptoms of dumping syndrome by increasing the speed of gastric emptying; it is better to drink fluids between meals.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.