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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).

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A Reason: Demonstrating how to complete an adverse occurrence or variance report is important, but not the most important objective. This report is a tool for quality improvement and risk management, but it does not prevent litigation by itself. The nurse should also communicate effectively with the client and/or their family, and document the incident and the actions taken.

Choice B Reason: Discussing how to handle complaints from clients and/or their families is the most important objective, as it can help prevent or resolve conflicts, and avoid escalation to legal action. The nurse should listen empathetically, acknowledge the client's feelings and concerns, apologize if appropriate, explain the situation and the plan of care, and involve the supervisor or other resources if needed.

Choice C Reason: Describing how to obtain legal services if needed is relevant, but not the most important objective.

This objective implies that litigation is inevitable or expected, which may create a negative or defensive attitude in the staff nurses. The nurse should focus on preventing litigation by providing safe and quality care and building trust and rapport with the clients and/or their families.

Choice D Reason: Maintaining personal malpractice insurance is advisable, but not the most important objective. This objective may protect the nurse's personal assets in case of a lawsuit, but it does not prevent litigation from occurring. The nurse should follow the standards of practice and the policies and procedures of the organization, and document accurately and thoroughly.

A. Document the occurrence in the client's record. B. Obtain a prescription for a nicotine patch during hospitalization. C. Educate the client about the hospital smoking policy. D. Notify the charge nurse about the situation immediately.

Correct Answer is D

Explanation

Choice A Reason: This is not the first action because it does not address the safety risk of smoking in the hospital. The nurse should document the occurrence after taking appropriate measures to prevent fire and injury.

Choice B Reason: This is not the first action because it does not stop the client from smoking in the bathroom. The nurse should obtain a prescription for a nicotine patch if the client agrees to quit smoking, but this is not a priority at this time.

Choice C Reason: This is not the first action because it does not ensure that the client will comply with the hospital smoking policy. The nurse should educate the client about the health hazards of smoking and the hospital rules, but this can be done later.

Choice D Reason: This is the best action because it alerts the authority figure who can intervene and enforce the hospital smoking policy. The nurse should notify the charge nurse as soon as possible to prevent fire and injury.

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