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Exhibits

Select the top 5 client findings that require immediate follow-up

Abdomen rigid with decreased bowel sounds

Glucose 220mg/d

No dialysis for 24 hours

Crackles throughout the lungs

WBC 17,000 mm3

Hemoglobin 10g/dL

Potassium 7mEq/L

Creatinine 3 mg/dL

Answer and Explanation

Correct Answer : A,B,D,E,G

A. Abdomen rigid with decreased bowel sounds: A rigid, tender abdomen suggests peritonitis, a life-threatening complication of peritoneal dialysis requiring immediate intervention.

B. Glucose 220 mg/Dl: Elevated glucose is concerning but not immediately life-threatening compared to the other findings.

C. No dialysis for 24 hours: Missing dialysis leads to toxin accumulation, hyperkalemia, and fluid overload, all of which can be life-threatening.

D. Crackles throughout the lungs: Fluid overload can cause pulmonary edema, leading to respiratory distress. Immediate intervention is needed to prevent respiratory failure.

E. WBC 17,000 mm³: Leukocytosis suggests infection, possibly peritonitis, which requires urgent antibiotic therapy.

F. Hemoglobin 10 g/dL: Mild anemia is expected in CKD and not an emergency.

G. Potassium 7 mEq/L: Severe hyperkalemia is a medical emergency due to the risk of life-threatening cardiac arrhythmias.

H. Creatinine 3 mg/dl: Creatinine is chronically elevated in CKD and not an acute concern.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Serum potassium 4.8 mmol/L: This is a normal potassium level (3.5–5.0 mmol/L) and indicates successful treatment.

B. Serum glucose 58 mg/dL: IV insulin drives potassium into cells, lowering serum potassium. However, insulin also lowers blood glucose, which can lead to hypoglycemia (glucose <70 mg/dL). Hypoglycemia is the primary adverse effect of IV insulin therapy.

C. Serum sodium 138 mEq/L: This is a normal sodium level (135–145 mEq/L) and not an adverse effect.

D. Calcium level of 100 mg: Calcium is not directly affected by IV insulin therapy.

A. Cardiac arrest B. Falling through the ice C. Head trauma D. Drug use

Correct Answer is A

Explanation

A. Cardiac arrest: Cardiac arrest is a complication of severe hypothermia, not a risk factor.

B. Falling through the ice: Major risk factor for accidental hypothermia due to immersion in cold water.

C. Head trauma: Impaired thermoregulation in the brainstem can cause hypothermia.

D. Drug use: Certain drugs (e.g., alcohol, sedatives) impair the body’s ability to regulate temperature, increasing hypothermia risk.

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Exhibits Select the top 5 client findings that require immediate follow-up

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hyperkalemia and is to receive intravenous insulin. Which of the following should the nurse recognize as an adverse outcome?

Correct Answer is B

Explanation

Which of the following is not a risk factor for accidental hypothermia?

Correct Answer is A

Explanation

What happens when a hypertonic IV solution is administered to a client?

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When a client is using a cooling blanket to reduce fever, which finding indicates the need to change treatment?

The nurse is reviewing the client's following arterial blood gases: pH 7.33, PaCo2 47, HCO3 24. Which manifestation would the nurse expect the client to be experiencing with this imbalance?

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Exhibits

Select the top 5 client findings that require immediate follow-up