The nurse working on a medical surgical unit is assigned four clients at the start of their shift. What client should be given the highest priority?

A 47-year-old client who reports two loose stools with a serum sodium of 139 mmol/L

A 71-year-old client with a calcium level of 8.9 mg/dL and a negative Trousseau sign

A 52-year-old client with fluid volume excess and BUN of 18 mg/dL

A 60-year-old client with a serum potassium of 3.2 mEq/L and heart palpitations

Answer and Explanation

The Correct Answer is D

A. A 47-year-old client who reports two loose stools with a serum sodium of 139 mmol/L: Although diarrhea can lead to electrolyte imbalances, a serum sodium level of 139 mmol/L is within normal range, so this client is not the highest priority.
B. A 71-year-old client with a calcium level of 8.9 mg/dL and a negative Trousseau sign: A calcium level of 8.9 mg/dL is slightly low but not critically low, especially with a negative Trousseau sign. This client is stable compared to others.
C. A 52-year-old client with fluid volume excess and BUN of 18 mg/dL: A BUN of 18 mg/dL indicates mild elevation, and fluid volume excess can be managed with adjustments in treatment; this client does not require immediate priority.
D. A 60-year-old client with a serum potassium of 3.2 mEq/L and heart palpitations: A potassium level of 3.2 mEq/L indicates hypokalemia, which can cause serious cardiac issues and symptoms like palpitations. This client requires urgent attention to address the potential risk of cardiac complications.

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Correct Answer is B

Explanation

A. Infiltration: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue, typically causing swelling and coolness, but not usually a cord-like vein or a reddened streak.
B. Phlebitis: This is the correct choice. Phlebitis is inflammation of the vein, evidenced by tenderness, burning, swelling, and a reddened streak along the vein. The cord-like vein indicates inflammation.
C. Extravasation: Extravasation involves the leakage of vesicant drugs into surrounding tissue, which can cause severe tissue damage, but usually involves more than just a cord-like vein and reddened streak.
D. Infection: Infection typically presents with more systemic signs like fever and could involve purulent discharge, which is not described in this scenario.

A. Ask why the client is taking steroid therapy B. Notify the surgeon immediately C. Administer an IV equivalent dose of Prednisone D. Give the oral steroid with a small sip of water

Correct Answer is C

Explanation

A. Ask why the client is taking steroid therapy: While understanding the reason for steroid therapy is important, it does not address the immediate need to manage the medication administration.
B. Notify the surgeon immediately: Notifying the surgeon might be necessary if there are specific concerns, but it is not the most immediate action regarding medication administration.
C. Administer an IV equivalent dose of Prednisone: Since the client is NPO, administering an oral medication could be contraindicated. Administering an IV equivalent ensures the client receives the necessary steroid therapy without risking complications from taking oral medication while fasting.
D. Give the oral steroid with a small sip of water: This may not be appropriate due to the NPO status, which typically restricts oral intake.

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The nurse working on a medical surgical unit is assigned four clients at the start of their shift. What client should be given the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After having an intravenous (IV) line in place for 72 hours, a client complains of tenderness, burning, and swelling. Assessment of the IV site reveals a cord-like vein and a reddened streak. The nurse identifies that these findings indicate what complication?

Correct Answer is B

Explanation

A client is scheduled for surgery at 0800 and has been NPO (nothing by mouth) since midnight. They have been taking long-term oral steroids and are scheduled for their routine dose of Prednisone 30 mg PO to be administered at 0600. Which nursing action is most appropriate?

Correct Answer is C

Explanation

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

The nurse is reviewing serum laboratory values for a client who is scheduled for surgery tomorrow. Which value requires the nurse to promptly notify the surgeon?

A client with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding related to the imbalance indicates that the client's compensatory mechanisms are working?

The nurse is caring for a client with a serum magnesium of 2.9 mEq/L. The nurse should anticipate a prescription from the primary healthcare provider for what treatment?

A nurse is providing education in a community setting to several clients taking daily calcium supplements and encourages them to drink 2,500 mL of fluid daily. The nurse explains that this intervention is important to prevent which complication?

The client is NPO and is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter. Which precautions should the nurse implement? (Select All That Apply)

Orders were written for a client to be weaned off of total parenteral nutrition (TPN) and started on a low-residue diet. The TPN solution has been infusing at a continuous rate of 90 ml/hr for three weeks. Which of the following orders should the nurse anticipate next?