The nurse is renewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L, Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

Obtain a 12 lead ECG

Request an electroencephalogram (FEC)

Assess for Chvostek's sign

Obtain a chest X-ray.

Answer and Explanation

The Correct Answer is A

A) Obtain a 12-lead ECG:
The client’s potassium level of 6.6 mEq/L is significantly elevated which places the patient at risk for cardiac arrhythmias. Elevated potassium levels can cause dangerous changes in the electrical activity of the heart, leading to peaked T waves, widened QRS complexes, and even cardiac arrest. A 12-lead ECG is necessary to assess the heart's electrical activity and to identify any potential arrhythmias

B) Request an electroencephalogram (EEG):
An EEG is used to assess brain activity and is typically indicated for conditions such as seizures or epilepsy. This client’s laboratory findings do not suggest a neurological concern that would warrant an EEG.

C) Assess for Chvostek's sign:
Chvostek's sign is used to assess for hypocalcemia or tetany, where a twitching of the facial muscles occurs upon tapping the facial nerve. However, the client’s primary issue here is elevated potassium levels, which are a more immediate concern than hypocalcemia. Hyperkalemia can have more severe and urgent consequences, particularly for the heart, so Chvostek's sign is not the priority at this time.

D) Obtain a chest X-ray:
A chest X-ray is not indicated based on the client’s current electrolyte imbalance or renal failure status. While a chest X-ray may be useful for various other concerns, the client’s elevated potassium level is the primary issue, and the priority intervention is to assess and manage the potential for cardiac arrhythmias with a 12-lead ECG.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Promptly change out of wet clothing such as bathing suits after use":
This is a key recommendation for preventing urinary tract infections (UTIs), especially in women. Wet clothing, such as swimsuits or damp exercise clothes, creates a warm, moist environment that encourages bacterial growth, particularly in the genital and perineal areas. Changing out of wet clothing promptly helps reduce the risk of bacteria entering the urinary tract, which is an important preventive measure for recurrent UTIs.

B. "Buy synthetic underwear rather than cotton fabric":
This statement is incorrect. Cotton underwear is recommended because it is breathable and helps keep the genital area dry, reducing the likelihood of bacterial growth. Synthetic fabrics, on the other hand, trap moisture and heat, creating an environment where bacteria can thrive, increasing the risk of UTIs. Therefore, wearing cotton underwear is advised rather than synthetic fabric.

C. "Be sure to empty your bladder every 6-8 hours":
This recommendation is somewhat inaccurate. To prevent UTIs, it is essential to empty the bladder more frequently than every 6-8 hours, especially if the person feels the urge to urinate. Holding urine for long periods can increase the risk of bacterial growth in the urinary tract. It is generally recommended to urinate at least every 3-4 hours during the day to prevent urine stagnation and reduce the risk of infection.

D. "Try to drink 500-1000 ml of fluid per day":
This fluid intake recommendation is too low. To prevent UTIs, a higher fluid intake is necessary—typically 2-3 liters (2000-3000 mL) of fluid per day. Adequate hydration helps ensure frequent urination, which flushes out bacteria from the urinary tract. Consuming only 500-1000 mL of fluid per day is insufficient and would likely increase the risk of UTIs due to less frequent urination and less flushing of the urinary system.

Correct Answer is ["250"]

Explanation

Given:

Total volume to infuse: 250 mL

Infusion time: 60 minutes

To find:

Infusion rate (mL/hr)

Step 1: Calculate the infusion rate in mL/min

Infusion rate (mL/min) = Total volume / Infusion time

Infusion rate (mL/min) = 250 mL / 60 minutes = 4.17 mL/min

Step 2: Convert mL/min to mL/hr

Infusion rate (mL/hr) = Infusion rate (mL/min) x 60 minutes/hr

Infusion rate (mL/hr) = 4.17 mL/min x 60 minutes/hr = 250 mL/hr

Therefore, the nurse should set the pump to deliver 250 mL/hr.

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The nurse is renewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L, Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a female client about reducing the recurrence of urinary tract infections. Which of the following statements should pre nurse make?

Correct Answer is A

Explanation

Correct Answer is ["250"]

Explanation

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