A nurse is assessing a newly admitted client with a history of chronic heart failure who has new onset confusion after forgetting to take his medications for a few days. The client has peripheral edema, mild shortness of breath, and bilateral crackles in the lung bases. Which of the following assessments is the priority for the nurse?

Capillary refill and depth of peripheral edema

Abdominal sounds and obtain a BNP level

Neurological status and obtain electrolyte levels

Skin turgor and measure intake & output (I&O)

Answer and Explanation

The Correct Answer is C

A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.

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Correct Answer is C

Explanation

A. "I will increase my fluid and fiber intake while I am taking iron tablets.": This statement is correct as increasing fluid and fiber can help manage constipation, a common side effect of iron supplementation.
B. "I will take the tablets with water an hour before eating.": This is correct because taking iron supplements on an empty stomach can improve absorption, and water helps dissolve the tablets.
C. "I will immediately call my health care provider if my stools turn green.": This statement indicates a misunderstanding, as green stools are a common and harmless side effect of iron supplements. They are not typically a cause for concern unless accompanied by other symptoms.
D. "I will take a stool softener if I occasionally feel constipated.": This is a correct and appropriate approach, as stool softeners can help alleviate constipation caused by iron supplements.

A. Client's serum pH is 7.41 B. Client has a stage 2 sacral wound C. Client requires continuous nasogastric suction D. Client has a history of adrenal insufficiency

Correct Answer is C

Explanation

A. Client's serum pH is 7.41: This is within the normal range for blood pH (7.35-7.45) and does not specifically indicate a potassium deficit.
B. Client has a stage 2 sacral wound: This is related to skin integrity and does not directly impact potassium levels.
C. Client requires continuous nasogastric suction: Continuous nasogastric suction can lead to the loss of potassium as it removes gastric contents, which may include electrolytes.
D. Client has a history of adrenal insufficiency: While adrenal insufficiency can affect electrolyte balance, continuous nasogastric suction is a more immediate risk for potassium deficit.

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Naxlex Comprehensive Predictor Exams

The nurse is educating a client on the use of oral ferrous sulfate. Which statement made by the client requires a need for further education?

Correct Answer is C

Explanation

The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?

Correct Answer is C

Explanation

The nurse working on a medical surgical unit is assigned four clients at the start of their shift. What client should be given the highest priority?

A nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL. Which condition most likely caused this serum phosphorus level?

The nurse identifies that which of the following clients is at risk for developing metabolic acidosis? (Select All That Apply)

After having an intravenous (IV) line in place for 72 hours, a client complains of tenderness, burning, and swelling. Assessment of the IV site reveals a cord-like vein and a reddened streak. The nurse identifies that these findings indicate what complication?

During a preoperative review of systems, the client reveals a history of renal disease. This finding suggests the need for which relevant preoperative diagnostic tests?

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