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 ["0.75"]
Explanation
To calculate the amount of mL to administer, the PN should use the following formula:
mL = (mcg x 1 mg/1000 mcg) / (mg/mL)
Plugging in the given values, we get:
mL = (150 x 1/1000) / (0.2)
mL = 0.15 / 0.2
mL = 0.75
Therefore, the PN should administer 0.75 mL of octreotide subcutaneously.
Correct Answer is D
Explanation
A) Incorrect- While notifying the healthcare provider is an important step to take after an error, it's not the first action the nurse should take. The immediate concern is the client's safety and well-being, so assessing the client for any adverse effects of the incorrect dose is the priority.
B) Incorrect- Documentation is important, but it's not the first action to take after administering an incorrect medication dose. The nurse should prioritize assessing the client for any adverse effects and ensuring their immediate safety.
C) Incorrect- Completing an incident report is an important step to document errors and prevent future occurrences, but it's not the initial action to take. First, the nurse should focus on the client's well-being by assessing for adverse effects.
D) Correct- Assessing the client for any adverse effects is the immediate priority when an incorrect dose of medication has been administered. The nurse's first concern is the safety and health of the client. Once the client's condition has been assessed and stabilized, further actions can be taken, such as notifying the healthcare provider and completing incident reports.
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