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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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A reason: This client has signs of dehydration and fluid volume deficit, which can lead to shock, a life-threatening condition that occurs when the body's organs are not receiving enough blood flow. The nurse should monitor the client's vital signs, urine output, skin color, and level of consciousness, and report any changes to the physician.

Choice B reason: Initiating enteric precaution procedures is important to prevent the spread of infection, as vomiting and diarrhea may be caused by a contagious pathogen. However, this is not the most important action for the nurse to implement, as it does not address the client's immediate risk of shock.

Choice C reason: Reducing light, noise and temperature may help the client feel more comfortable and reduce nausea, but it is not the most important action for the nurse to implement, as it does not address the client's fluid volume deficit and potential shock.

Choice D reason: Encouraging electrolyte supplements may help replenish the electrolytes lost through vomiting and diarrhea, but it is not the most important action for the nurse to implement, as it may not be enough to restore the fluid balance and prevent shock. The client may need intravenous fluids and medications to correct the dehydration and hypotension.

A. One hour after receiving hydromorphone prescribed for every 4 hours PRN use, a client reports severe pain. B. Two hours after receiving morphine for acute pain, a client's vital signs are BP 112/60 mm Hg, pulse 88 beats/minute, and respirations 14 breaths/minute. C. After ambulating, a postoperative client grimaces and reports incisional pain at a "9 on a ten-point scale". D. The fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced.

Correct Answer is C

Explanation

Choice A Reason: This client may need another dose of hydromorphone if the pain is not relieved by the previous one. A PN can administer this medication under the supervision of a RN and monitor the client's response.

Choice B Reason: This client's vital signs are within normal limits and indicate that the morphine is effective and not causing respiratory depression. A PN can assess and document the client's vital signs and pain level.

Choice C Reason: This is the correct answer because this client has acute and severe pain that may require immediate intervention and reassessment. An RN can evaluate the cause and severity of the pain, administer additional analgesics as prescribed, and implement nonpharmacological measures to relieve the pain.

Choice D Reason: This client has chronic and stable pain that is managed by a fentanyl patch. A PN can replace the patch according to the schedule and instructions provided by the RN.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with tachycardia and hypotension presents to the emergency department (ED) reporting severe vomiting and diarrhea for three days. Which action is most important for the nurse to implement?

Correct Answer is A

Explanation

It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?

Correct Answer is C

Explanation

The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision?

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