After reviewing the morning laboratory findings for four clients, which client should the nurse follow up with first? Reference Range:
International Normalized Ratio [0.8 to 1.1]
Blood Glucose 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
Brain Natriuretic Peptide (BNP) [less than 100 pg/mL (less than 100 ng/L)]
The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L).
The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5.
The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L).
The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).
The Correct Answer is A
Choice A Reason: This client has a very high BNP level, which indicates severe heart failure and fluid overload. The nurse should follow up with this client first, as they may need urgent interventions such as oxygen therapy, diuretics, and vasodilators.
Choice B Reason: This client has an INR within the therapeutic range for warfarin therapy, which is usually between 2 and 3. The nurse should monitor this client for signs of bleeding or clotting, but they do not require immediate follow-up.
Choice C Reason: This client has a mildly elevated glucose level, which may be caused by the corticosteroids that
increase blood sugar. The nurse should check the client's blood glucose regularly and administer insulin as ordered, but they do not require immediate follow-up.
Choice D Reason: This client has a normal potassium level, which is within the reference range of 3.5 to 5 mEq/L. The nurse should ensure that the client is ready for dialysis and avoid foods high in potassium, but they do not require immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is the best action because it describes the current situation of the client and alerts the family to a possible change in the client's status. The nurse should provide the most relevant and urgent information first using the SBAR communication.
Choice B Reason: This is not the first action because it does not address the current situation of the client. The nurse should verify the client's healthcare power of attorney, but this is not a priority at this time.
Choice C Reason: This is not the first action because it does not explain the cause of the client's confusion. The nurse should review the client's medications and assess for any adverse effects, but this is not a priority at this time.
Choice D Reason: This is not the first action because it provides background information that is not directly related to the current situation of the client. The nurse should give a brief history of the client's admission, but this can be done later.
Correct Answer is A
Explanation
Choice A Reason: This is the correct answer because the client's vital signs indicate that she is hypovolemic and dehydrated due to the leakage of gastric contents from the anastomosis site. The nurse should replace fluids intravenously to prevent shock and electrolyte imbalance.
Choice B Reason: Recording the amount of daily wound drainage is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should monitor the wound drainage for signs of infection and report any changes to the physician.
Choice C Reason: Assessing skin condition and turgor for breakdown is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should assess the skin for signs of dehydration and pressure ulcers and provide appropriate skin care.
Choice D Reason: Turning every 2 hours around the clock from side-to-side is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should turn the client to prevent complications such as pneumonia and atelectasis but also consider the client's comfort and pain level.
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