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","C"]
Explanation
Choice A Reason: Identifying locations of skin lesions on a newly admitted client is a nursing assessment that requires clinical judgment and cannot be delegated to the UAP.
Choice B Reason: Emptying the ostomy bag for a client with a temporary colostomy is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice C Reason: Providing a complete bed bath for a comatose client is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice D Reason: Performing foot care including toenail trimming and heel care is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause injury or infection to the client's feet, especially if the client has diabetes or peripheral vascular disease.
Choice E Reason: Giving mouth care to an elderly client who has a tracheostomy is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause trauma or aspiration to the client's trachea, especially if the client has poor oral hygiene or respiratory secretions.
Correct Answer is A
Explanation
Choice A Reason: This is the best action because it prevents the spread of infection to other clients and staff. Mumps is a viral infection that causes inflammation of the salivary glands and can be transmitted by respiratory droplets. The nurse should place an isolation cart outside of the room and wear a mask, gloves, and gown when entering.
Choice B Reason: This is not the first priority because it does not address the risk of infection. The nurse should schedule bedside play time with the occupational therapist to promote the child's development and coping, but this can be done later.
Choice C Reason: This is not the first priority because it does not ensure that infection control measures are in place. The nurse should instruct the child's parents about the need for transmission precautions and educate them on how to care for their child at home, but this can be done later.
Choice D Reason: This is not the first priority because it does not prevent the spread of infection. The nurse should assign the child to a room close to the nurse's station to monitor his condition and provide comfort, but this is not a critical intervention.
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