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

Answer and Explanation

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.

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Correct Answer is ["B","D","E"]

Explanation

A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This is a sign of infiltration as fluid accumulates in the tissue around the IV site.
C. The vein is firm and cord-like: This is indicative of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a clear sign of infiltration, where fluid leaks out of the vein into surrounding tissue.
E. Warmth at the insertion site: This can be a sign of infiltration or inflammation, depending on the context.

A. Discontinue the intravenous line B. Complete an incident report C. Start a new IV in the right hand D. Place a warm compress over the site E. The correct answer is A.

Correct Answer is A

Explanation

A. Discontinue the intravenous line: The presence of tenderness and a red streak suggests phlebitis or possibly an early sign of infection. The first and most important step is to discontinue the IV line to prevent further irritation or infection.
B. Complete an incident report: While documentation is important, it is not the first action to take. Immediate attention should be given to the client’s physical condition before completing any paperwork.
C. Start a new IV in the right hand: While starting a new IV is necessary for continued therapy, the first action should be to remove the current IV line to prevent further complications. Starting a new IV can be done immediately afterward.
D. Place a warm compress over the site: A warm compress can help alleviate pain and reduce inflammation, but the priority action is to discontinue the IV line to stop further damage or infection.

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After receiving the change of shift report, the nurse reviews the electronic health record for each client. What client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

Correct Answer is ["B","D","E"]

Explanation

The client has received IV solution for three (3) days through a 20-gauge IV catheter placed in the left hand. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

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A client has been receiving IV potassium therapy. Upon further assessment, the nurse notes the site has become erythematous and edematous. Which action by the nurse is most appropriate?

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