The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take?

Auscultate for irregular heart rate.

Monitor daily sodium intake.

Document abdominal girth.

Measure ankle circumference

Answer and Explanation

The Correct Answer is A

A)   Correct- Electrolyte imbalances, particularly involving electrolytes like potassium, can lead to cardiac arrhythmias. Elevated blood pressure can strain the cardiovascular system, and mental status changes could indicate potential neurologic and cardiovascular involvement. Auscultating for an irregular heart rate helps identify any immediate cardiac issues that require intervention.
B)   Incorrect- While monitoring sodium intake is important for clients with chronic kidney disease, it is not the most urgent action in this scenario. The presence of electrolyte imbalance, elevated blood pressure, and changes in mental status indicate a more acute concern that requires immediate assessment.
C)   Incorrect- Documenting abdominal girth is relevant for assessing fluid status, but in this situation, the presence of electrolyte imbalance, elevated blood pressure, and mental status changes indicates a more critical issue that requires prompt intervention.

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Correct Answer is A

Explanation

A. Obtain emergency help. - This is the most urgent action as the client is unresponsive, and getting emergency assistance is crucial to providing immediate care.
B. Feel for a carotid pulse. - While assessing the pulse is important, if the client is unresponsive, the first step is to get emergency assistance.
C. Bring a glucometer to the room. - This action might be relevant for assessing specific conditions, but in this scenario, the priority is to seek immediate emergency assistance.
D. Check the blood pressure. - Assessing blood pressure is important, but in the case of an unresponsive client, seeking emergency help takes precedence for immediate assistance and care.

A. The ﬂowmeter shows 1 liter of oxygen being delivered. B. There is no humidifier attached to the delivery system. C. The client is lying in a supine position in the bed. D. The cannula is pressed snugly against the client's cheeks.

Correct Answer is A

Explanation

This finding requires immediate action, as it indicates that the client is not receiving the prescribed amount of oxygen, which can compromise the oxygenation and perfusion of the tissues. The PN should adjust the ﬂowmeter to deliver 3 liters per minute of oxygen, and check for any leaks or kinks in the tubing.

The other options are not correct because:

B. The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation.

C. The supine position does not require immediate action, as it is not a contraindication for oxygen therapy. The client may prefer this position for comfort or rest, and it does not aﬀect the oxygen delivery or uptake.

D. The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen ﬂow or diﬀusion.

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The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

Correct Answer is A

Explanation

The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action?

Correct Answer is A

Explanation

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