A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

Administer an IV potassium drip.

Listen to the client's bowel sounds.

Check the client's hand grasps.

Initiate cardiac monitoring for the client.

Answer and Explanation

The Correct Answer is D

The client has hypokalemia, which is a low level of potassium in the blood. Hypokalemia can cause cardiac arrhythmias, which can be life-threatening. The nurse should initiate cardiac monitoring first to assess the client's heart rhythm and rate, and intervene if any abnormalities are detected. Administering an IV potassium drip is an appropriate intervention for hypokalemia, but it is not the first priority. Listening to the client's bowel sounds and checking the client's hand grasps are also relevant assessments for hypokalemia, as it can cause decreased bowel motility and muscle weakness, but they are not as urgent as cardiac monitoring.

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Correct Answer is D

Explanation

A low potassium level (hypokalemia) can increase the risk for digoxin toxicity because it enhances the binding of digoxin to cardiac cells and increases its effects on cardiac contractility and electrical conduction. The nurse should monitor the client's potassium level and administer potassium supplements as prescribed if needed. The other electrolytes are not directly related to digoxin toxicity.

A. Contact the client's power of attorney to sign the consent. B. Inform a family member of the need to sign the consent. C. Notify the surgical team that the client is unable to sign the consent. D. Allow the client to sign the consent with an X

Correct Answer is D

Explanation

Allow the client to sign the consent with an X. The client has the right to give informed consent if they understand the procedure and its risks and benefits, even if they cannot read or write. The nurse should witness and document the client's signature with an X and verify their identity and understanding. The other options are not appropriate because they violate the client's autonomy and dignity.

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A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk for digoxin toxicity?

Correct Answer is D

Explanation

A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reviewing the following ABG results for a postoperative client: pH 7.27, PaCO2 49 mm Hg, PaO2 65 mm Hg, HCO 22 mEq/L. The nurse should interpret the findings as which of the following imbalances?

A nurse is caring for a client who has been receiving total parenteral nutrition (TPN) for 1 week. For which of the following findings should the nurse notify the provider?

A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

A nurse is assessing a client who has increased intracranial pressure (ICP). The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?

A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon?

A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have at the bedside?

A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching?