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 B
Explanation
Choice A Reason: Contacting the healthcare provider is not the priority action because restraints should only be used as a last resort and not for staff convenience. The nurse manager should first ensure that the client's safety and dignity are respected.
Choice B Reason: This is the correct answer because restraints are not indicated for this situation and violate the client's rights. The nurse manager should educate the staff nurse about the ethical and legal implications of using restraints without proper justification and documentation.
Choice C Reason: Closing the door to the room is not a priority action because it does not address the issue of restraints. It also may isolate the client and increase her anxiety and distress.
Choice D Reason: Determining if the client has a PRN prescription for an antianxiety agent is not a priority action because it does not address the issue of restraints. It also may not be appropriate to medicate the client without assessing her condition and obtaining her consent.
Correct Answer is B
Explanation
Choice A Reason: Ensuring the transfer of the client's electronic chart code is not the most important action for the nurse to take first. The electronic chart code is a unique identifier that allows access to the client's health records and care plan. While this is an important task, it is not as urgent or essential as giving a detailed report to the accepting nurse, who will be responsible for providing palliative care to the client.
Choice B Reason: Giving a detailed report to the accepting nurse is the most important action for the nurse to take first. The report should include the client's diagnosis, prognosis, pain level, medication regimen, preferences, goals, and psychosocial needs. This will ensure continuity of care and facilitate a smooth transition for the client and the family.
Choice C Reason: Taking the family to the client's new room is not the most important action for the nurse to take first. The family may need emotional support and guidance during this difficult time, but they also need accurate and timely information about the client's condition and care plan. The nurse should first give a detailed report to the accepting nurse and then accompany the family to the new room.
Choice D Reason: Giving the client written information about end-of-life care is not the most important action for the nurse to take first. The client may benefit from learning more about palliative care, hospice care, advance directives, and bereavement services, but this should be done after giving a detailed report to the accepting nurse and ensuring that the client is comfortable and stable in the new room.
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