The nurse is reviewing serum laboratory test results of a client receiving diuretic therapy. The nurse determines the client is at risk for electrolyte imbalance based on which result(s)? (Select all that apply)

Potassium 2.9 mEq/L

Sodium 125 mEq/L

Potassium 4.6 mEq/L

Sodium 139 mEq/L

Magnesium 2.1 mEq/L

Answer and Explanation

Correct Answer : A,B

A. Potassium 2.9 mEq/L: This indicates hypokalemia, which is a common electrolyte imbalance associated with diuretic therapy, particularly with loop diuretics.
B. Sodium 125 mEq/L: This indicates hyponatremia, another possible electrolyte imbalance resulting from diuretic use.
C. Potassium 4.6 mEq/L: This is within the normal range and does not indicate an imbalance.
D. Sodium 139 mEq/L: This is within the normal range and does not indicate an imbalance.
E. Magnesium 2.1 mEq/L: This is within the normal range and does not indicate an imbalance.

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Correct Answer is C

Explanation

A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.

A. Tell the client he can no longer have any more pain medication B. Notify the prescribing physician C. Administer half the dose of morphine, 2 mg IV D. Administer 4 mg of morphine IV as ordered

Correct Answer is B

Explanation

A. Tell the client he can no longer have any more pain medication: This is not appropriate. The client’s severe pain needs to be managed, but the current vital signs suggest a need for careful evaluation before administration.
B. Notify the prescribing physician: This is the correct choice. The client's blood pressure and respiratory rate are significantly low, which could be exacerbated by morphine. The physician needs to be informed to reassess pain management and possibly adjust the treatment.
C. Administer half the dose of morphine, 2 mg IV: Given the client's low blood pressure and respiratory rate, any morphine administration could worsen these issues. Adjusting the dose without physician guidance is not appropriate.
D. Administer 4 mg of morphine IV as ordered: Administering the full dose without addressing the client’s low blood pressure and respiratory rate could lead to severe complications.

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The nurse is reviewing serum laboratory test results of a client receiving diuretic therapy. The nurse determines the client is at risk for electrolyte imbalance based on which result(s)? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

Correct Answer is B

Explanation

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