After receiving change-of-shift report, which client should the nurse assess first?

Client with serum phosphorus level of 4.5 mg/dL.

Client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes.

Client with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping.

Client with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water.

Answer and Explanation

The Correct Answer is B

A. Client with serum phosphorus level of 4.5 mg/dL: This is within the normal range for phosphorus (2.5-4.5 mg/dL), and the client does not require immediate assessment.

B. Client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes: This is the correct answer. A magnesium level of 1.1 mEq/L is below the normal range (1.5-2.5 mEq/L), and symptoms like tremors and hyperactive reflexes indicate hypomagnesemia, which can lead to serious complications such as arrhythmias.

C. Client with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping: A potassium level of 5.0 mEq/L is within the normal range (3.5-5.0 mEq/L), so this client does not need immediate intervention.

D. Client with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water: A sodium level of 145 mEq/L is at the upper end of normal (135-145 mEq/L), and the symptoms are likely due to dehydration or a normal response.

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Correct Answer is D

Explanation

A. Administering multiple vitamins and minerals via IV alone would not be sufficient for adequate nutrition in this patient, especially given the large burn surface area.

B. Total parenteral nutrition (TPN) may be used if enteral feeding is not possible, but enteral feeding is usually preferred when feasible.

C. Encouraging oral intake is not appropriate for a client with a 60% TBSA burn, as they would likely require more significant nutritional support than oral intake can provide.

D. Enteral feeding is the preferred method for nutrition in burn patients as it maintains gut integrity and prevents the complications associated with parenteral nutrition. Although the client has absent bowel sounds and a distended abdomen, this can be common early in burn care, and enteral feedings should be started as soon as feasible to prevent malnutrition and promote recovery.

A. "My legs cramp when I walk more than a block." B. "I get short of breath when I climb a lot of stairs." C. "When I stand for too long, my feet start to swell." D. "My fingers hurt when I go outside in cold weather."

Correct Answer is A

Explanation

A. Intermittent claudication is characterized by cramping pain in the legs during physical activity, such as walking, due to insufficient blood flow, typically caused by peripheral arterial disease (PAD). This statement aligns with the symptoms of claudication.

B. Shortness of breath during physical exertion is more indicative of cardiovascular or pulmonary issues, not intermittent claudication.

C. Swelling in the feet from standing for extended periods is more consistent with venous insufficiency rather than intermittent claudication.

D. Pain in the fingers due to cold weather suggests Raynaud’s phenomenon, not intermittent claudication.

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After receiving change-of-shift report, which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has just been admitted with a 60% total body surface area (TBSA) burn injury. The nurse notes a distended abdomen with absent bowel sounds in all quadrants. To maintain adequate nutrition, the nurse should plan to take which action?

Correct Answer is D

Explanation

While working in the outpatient clinic, the nurse notes that the client has a history of intermittent claudication. Which statement by the client would support this information?

Correct Answer is A

Explanation

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