A nurse is planning care for a client who was recently admitted to the medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential condition:

The client's admission assessment reveals symptoms consistent with SLE, such as fever, joint discomfort, malaise, macular rash on the cheeks, and generalized pain.

The laboratory results show an elevated erythrocyte sedimentation rate (ESR), which is a common finding in SLE.

Action to take:

In managing this condition, the nurse should ensure that the client has an intake of at least 200 mL/hr to maintain adequate hydration, which is crucial for patients with SLE to help prevent kidney damage from inflammation. Additionally, the nurse should encourage the client to avoid direct sunlight, as UV rays can exacerbate SLE symptoms.

Parameters to monitor:

To monitor the client's progress, the nurse should regularly check the erythrocyte sedimentation rate to assess the level of inflammation. Vital signs should also be monitored every 4 hours to ensure stability and detect any changes that may require medical intervention.

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Correct Answer is D

Explanation

A. This would involve irregular beats and potentially a visible compensatory pause, not a prolonged PR interval.
B. Atrial fibrillation features an irregularly irregular rhythm and no discernible PR intervals.

C. Defined by a heart rate less than 60/min with a normal rhythm and electrical pattern, which does not apply here given the normal rate and prolonged PR interval.
D. A first-degree atrioventricular (AV) block is characterized by a prolonged PR interval (greater than 0.20 seconds) in the presence of a normal heart rate and rhythm, which aligns with the client’s PR interval of 0.24 seconds and a heart rate of 69/min

A. Increased bicarbonate B. Increased calcium C. Increased hemoglobin D. Increased creatinine

Correct Answer is D

Explanation

A. Chronic kidney disease often results in metabolic acidosis, leading to decreased bicarbonate levels rather than increased.
B. Chronic kidney disease commonly leads to hyperphosphatemia and hypocalcemia due to impaired renal excretion of phosphate and decreased activation of vitamin D, resulting in decreased calcium levels.
C. Chronic kidney disease often results in anemia due to decreased production of erythropoietin, leading to decreased hemoglobin levels rather than increased.
D. Increased creatinine levels are indicative of impaired renal function, a hallmark of chronic kidney disease.

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Naxlex Comprehensive Predictor Exams

A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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