Exhibits

Specify which potential condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s response.

Answer and Explanation

The Correct Answer is []

The client is most likely experiencing compartment syndrome, which is a condition where increased pressure within a closed space compromises blood flow and tissue perfusion. Compartment syndrome can occur after a fracture, especially if a cast or splint is applied too tightly. Some of the signs and symptoms of compartment syndrome are severe pain, paresthesia, pallor, and pulselessness.
Two actions the nurse should take to address compartment syndrome are:
- Elevate the extremity above the level of the heart to reduce swelling and improve venous return.
- Remove the cast or loosen the dressing to relieve the pressure and restore blood flow. This may require notifying the physician or obtaining an order for bivalving or cutting the cast.
Two parameters the nurse should monitor to assess the client’s condition are:
- Capillary refill of the affected fingers, which should be less than 3 seconds. A prolonged capillary refill indicates poor perfusion and tissue ischemia.
- Blood pressure of the client, which should be maintained within normal limits. Hypotension can worsen the perfusion deficit and lead to tissue necrosis.

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Correct Answer is A

Explanation

Choice A reason: Sodium polystyrene sulfonate is a medication that binds to excess potassium in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can cause cardiac arrhythmias and muscle weakness, and it is a common complication of AKI. Therefore, this medication should be administered first to lower the potassium level and prevent life-threatening complications.

Choice B reason: Sevelamer is a medication that binds to phosphorus in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperphosphatemia, which is a high level of phosphorus in the blood. Hyperphosphatemia can cause bone loss and soft tissue calcification, and it is a common complication of chronic kidney disease (CKD). However, it is not an urgent issue in AKI, and it does not affect the potassium level.

Choice C reason: Calcium acetate is a medication that also binds to phosphorus in the gastrointestinal tract and removes it from the body through feces. It has the same effect and indication as sevelamer, but it also provides calcium supplementation. However, it is not an urgent issue in AKI, and it does not affect the potassium level.

Choice D reason: Epoetin alfa, recombinant is a medication that stimulates the production of red blood cells in the bone marrow. It is used to treat anemia, which is a low level of hemoglobin or red blood cells in the blood. Anemia can cause fatigue, weakness, and shortness of breath, and it is a common complication of CKD and AKI. However, it is not an urgent issue in AKI, and it does not affect the potassium level.

A. Applies prescribed lotions to the radiation site. B. Washes the radiation site with antibacterial soap and water. C. Wears clothing to cover the radiation site. D. Dries the area with patting motions after taking a shower.

Correct Answer is B

Explanation

Choice A reason: Applying prescribed lotions to the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help moisturize and protect the skin from irritation and breakdown. The client should follow the instructions of the health care provider regarding the type and frequency of lotion application. Therefore, this choice does not indicate a need for further teaching.

Choice B reason: Washing the radiation site with antibacterial soap and water is a bad action for a client with cancer receiving external beam radiation, because it can cause dryness, inflammation, and infection of the skin. The client should use mild soap and water or saline solution to gently cleanse the area without rubbing or scrubbing. Therefore, this choice indicates a need for further teaching.

Choice C reason: Wearing clothing to cover the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help shield the skin from sun exposure and friction. The client should wear loose-fitting, soft, cotton clothing that does not irritate or constrict the area. Therefore, this choice does not indicate a need for further teaching.

Choice D reason: Drying the area with patting motions after taking a shower is a good action for a client with cancer receiving external beam radiation, because it can help prevent trauma and infection of the skin. The client should avoid rubbing or scratching the area or using hair dryers or heating pads on it. Therefore, this choice does not indicate a need for further teaching.

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Exhibits Specify which potential condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s response.

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Naxlex Comprehensive Predictor Exams

A client with acute renal injury (AKI) weighs 110.3 pounds (50 kg) and has a potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to the hospital. Which prescribed medication should the nurse administer first? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Correct Answer is A

Explanation

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

Correct Answer is B

Explanation

Patient Data Exhibits Drag from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

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Exhibits For each assessment finding, explain whether the actions taken were effective or ineffective.

Exhibits

Specify which potential condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s response.