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 C

Explanation

The client may be experiencing postoperative delirium, which is a transient state of confusion, disorientation, agitation, or hallucinations that can occur after surgery, especially in elderly clients. The PN should raise the side rails and notify the family to come and stay with the client, as this can provide safety, comfort, and reassurance for the client.

The other options are not correct because:

A. Administering a prescribed narcotic antagonist may not be appropriate or necessary, as the client's agitation may not be caused by analgesic accumulation, but by other factors such as hypoxia, infection, electrolyte imbalance, or sensory deprivation.

B. Notifying the healthcare provider and requesting a prescription for restraints may not be the best intervention, as restraints can increase the client's agitation, anxiety, or injury. Restraints should be used only as a last resort when other measures have failed or when there is an imminent risk of harm.

D. Instructing a UAP to keep the upper side rails up and check on the client every 15 minutes may not be sufficient or eﬀective, as the client may still try to get out of bed or become more agitated by being left alone. The PN should involve the family or stay with the client until he or she is calm and oriented.

A. Obtain emergency help. B. Feel for a carotid pulse. C. Bring a glucometer to the room. D. Check the blood pressure.

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.

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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

An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free. After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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