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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A) Correct - Clear beef broth is appropriate for a postoperative full-liquid diet, as it is a clear liquid and meets the dietary restrictions.
B) Correct - Vegetable juice can be included in a postoperative full liquid diet, as long as it is free of solid particles.
C) Incorrect - Canned fruit cocktails may contain solid pieces of fruit, which are not suitable for a full-liquid diet.
D) Correct - Vanilla frozen yogurt is a suitable option for a postoperative full-liquid diet, as it is in a liquid state when consumed.
E) Incorrect - Creamy peanut butter is not appropriate for a full-liquid diet, as it is a solid food and does not meet the diet's requirements.
Correct Answer is ["A","B","D"]
Explanation
They are needed to remove the saline lock safely and prevent bleeding or infection. The PN should wear exam gloves to protect themselves and the client from contamination, apply a small gauze pad over the insertion site, and secure it with paper tape after removing the saline lock.
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