After receiving the change of shift report, the nurse reviews the electronic health record for each client. What client should the nurse see first?
The client with a serum phosphorus of 4.5 mg/dL that requires assistance with planning their meals
The client with a serum magnesium of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
The client with a serum potassium of 5.3 mEq/L and is scheduled for hemodialysis in three hours
The client with a serum sodium of 145 mEq/L who is complaining of a dry mouth and wants a glass of water
The Correct Answer is B
A. The client with a serum phosphorus of 4.5 mg/dL that requires assistance with planning their meals: A serum phosphorus level of 4.5 mg/dL is within the normal range, and assistance with meal planning is a lower priority compared to the other situations.
B. The client with a serum magnesium of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes: This client has hypomagnesemia, which can lead to severe complications like seizures or cardiac arrhythmias. Immediate attention is necessary due to the symptoms and the critically low magnesium level.
C. The client with a serum potassium of 5.3 mEq/L and is scheduled for hemodialysis in three hours: This potassium level is slightly elevated, but the scheduled hemodialysis suggests the issue will be addressed soon.
D. The client with a serum sodium of 145 mEq/L who is complaining of a dry mouth and wants a glass of water: A serum sodium of 145 mEq/L is on the high end of normal; the client's dry mouth is concerning but not as urgent as the issues presented by the hypomagnesemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B"]
Explanation
B. Temperature 38.6°C (101.4°F): An elevated temperature in the postoperative period may indicate an infection, which requires immediate evaluation and management.
A. Heart rate 72 beats/min: This is within the normal range and does not indicate an urgent issue.
C. Surgical dressing dry and intact: This is a positive finding and does not require immediate attention.
D. Pain rating 3 out of 10: This level of pain is manageable and does not indicate a severe issue.
E. Limited ambulation: Limited ambulation is expected post-surgery and does not necessarily indicate an urgent problem.
Correct Answer is A
Explanation
A. Hypocalcemia: Hypocalcemia can cause signs such as muscle twitching, spasms, or tetany, which could be observed in the upper extremity and might be noted during a blood pressure measurement.
B. Hypokalemia: While hypokalemia can cause muscle weakness and cramping, it is less directly associated with specific upper extremity signs compared to hypocalcemia.
C. Hypophosphatemia: This generally affects energy levels and muscle function but is less commonly associated with immediate and visible upper extremity signs.
D. Hyponatremia: This primarily affects fluid balance and mental status, and is less likely to present with specific upper extremity findings during a blood pressure check.
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