Question

A client with a history of heart failure arrives at the emergency department describing an onset of fatigue and weakness. Theclient has been taking spironolactone 50 mg tablets PO every day. The nurse receives report from the lab that the client has a serum potassium level of 6.2 mEq/L (6.2 mmol/L). Which intervention is most important for the nurse to implement?

Answer 1

Correct Answers:

Determine apical pulse rate and rhythm.

Rationale :

🔔Hyperkalemia can cause life-threatening cardiac arrhythmias, which makes continuous monitoring of the heart’s electrical activity essential.

💓The apical pulse provides accurate information about rate and rhythm, helping to detect early signs of bradycardia or irregular heartbeats associated with elevated potassium levels.

⚡Muscle weakness and deep tendon reflexes may be affected but are not immediate threats compared to cardiac dysfunction.

🧪Urine assessment is important for renal function but does not address the most critical risk of hyperkalemia, which is cardiac arrest.

📌Core Message

Hyperkalemia requires immediate cardiac monitoring due to the risk of arrhythmias.

Answer 2

Correct Answers:

Risk for aspiration relative to muscle weakness.

Rationale :

🥄Clients with Parkinson's disease often develop dysphagia, increasing the risk of aspiration and possibly leading to aspiration pneumonia, a life-threatening condition.

🧠The neuromuscular impairment in Parkinson’s affects control over swallowing muscles, making aspiration a top safety concern.

📉While mobility and self-care are important, airway protection takes precedence when prioritizing care.

📋Constipation is a valid concern in Parkinson’s but does not pose the same level of immediate threat as aspiration.

📌Core Message

Airway protection is the top priority in Parkinson’s disease due to the risk of aspiration.

Answer 3

Correct Answers:

Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours.

Rationale :

🕒A 24-hour creatinine clearance test begins by discarding the first void, which sets the starting point for the timed collection.

🧴All urine voided thereafter must be collected to ensure accurate assessment of renal function over a full day.

📉Missing even one void can invalidate the entire test, making correct instructions crucial.

🧼Catheterization or sterile collection is unnecessary unless specifically ordered or if the client cannot void independently.

📌Core Message

Accurate 24-hour urine collection requires discarding the first void and collecting all urine afterward.

Answer 4

Correct Answers:

Initiate seizure precautions.

Rationale :

⚠️Benzodiazepine withdrawal can cause severe neurological symptoms including seizures, which pose an immediate danger.

🛏️The nurse’s priority is to protect client safety by initiating seizure precautions such as padding the bed and ensuring emergency equipment is nearby.

💊Naloxone is for opioid overdose, not benzodiazepines, and would not be effective.

📚Family education and drug screening are important but not initial priorities in an acute withdrawal scenario.

📌Core Message

Seizure precautions are the priority in benzodiazepine withdrawal due to the risk of seizures.

Answer 5

Correct Answers:

Falling from a ladder as reason for admission.

Rationale :

📞In SBAR communication, the “Situation” comes first and should clearly state why the client is seeking care—in this case, the fall.

📋This provides immediate context and urgency for the provider to understand the clinical concern.

💊Medications, confusion, and healthcare power of attorney are part of the Background and Assessment, not the initial statement.

📈Effective SBAR communication helps prioritize clinical decision-making.

📌Core Message

In SBAR, always begin with the immediate reason for care, the “Situation”.

Answer 6

Correct Answers:

Every 15 minutes for one hour, then every 1 hour for 2 hours.

Rationale :

📉Paracentesis can cause rapid fluid shifts, leading to hypotension, so frequent monitoring is necessary immediately after the procedure.

📊Monitoring every 15 minutes initially allows early detection of post-procedure complications like hypovolemia.

🕐After the first hour, less frequent checks are appropriate as the client stabilizes.

⛑️This schedule balances safety with efficiency in nursing care.

📌Core Message

After paracentesis, monitor BP frequently to detect fluid shift complications.

Answer 7

Correct Answers:

Swollen hands.
Headache.
Blurred vision.

Rationale :

🧠These are classic signs of preeclampsia, a potentially serious complication of pregnancy involving hypertension and organ involvement.

👁️Blurred vision and headaches may indicate neurological involvement, while swollen hands reflect fluid retention.

🥶Chills, fever, and urinary frequency are not specific indicators of preeclampsia.

📞Prompt recognition and reporting of these signs can prevent complications like seizures or eclampsia.

📌Core Message

Swelling, headache, and vision changes signal preeclampsia and must be reported promptly.

Answer 8

Correct Answers:

Encourage the parents to allow the child to continue attending swimming lessons With supervision.

Rationale :

🧒Children with Duchenne muscular dystrophy benefit from low-impact exercises like swimming, which promote strength without overfatigue.

👪Supervised swimming allows continued normal childhood activities and psychosocial development.

🛑Restricting activity too early can hinder physical and emotional well-being.

🤝Collaboration with healthcare providers ensures safe participation.

📌Core Message

Supervised low-impact activity like swimming supports physical and emotional health in Duchenne muscular dystrophy.

Answer 9

Correct Answers:

Reduce intestinal activity.

Rationale :

🔄In Crohn's disease, restricted activity reduces metabolic demands and peristalsis, helping minimize bowel stimulation.

⚙️This supports disease control and promotes healing of inflamed intestines.

😣Pain control and diarrhea reduction are secondary benefits of reduced intestinal workload.

📖Client education on activity restriction is key to effective disease management.

📌Core Message

Activity restriction in Crohn’s disease helps reduce bowel activity and support healing.

Answer 10

Correct Answers:

Wear protective goggles while performing the procedure.

Rationale :

🧪Oral suctioning exposes nurses to bodily fluids, making eye protection essential to prevent mucous membrane exposure.

🧯Suctioning can stimulate coughing, increasing risk of aerosolized secretions.

💧Lubrication and saline instillation are unnecessary for oral suctioning, and instructing the client to cough is not always possible in ALS due to muscle weakness.

😷Protecting the nurse while delivering care ensures infection control compliance.

📌Core Message

Always use eye protection during oral suctioning to prevent exposure to secretions.

2 :
In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

3 :
The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the client?

4 :
A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?

6 :
A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?

7 :
The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

8 :
The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

9 :
Restricted activity is prescribed for a client with Crohn's disease. The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?

10 :
The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

2 : In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

3 : The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the client?

4 : A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?

6 : A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?

7 : The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

8 : The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

9 : Restricted activity is prescribed for a client with Crohn's disease. The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?

10 : The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

2 :
In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

3 :
The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the client?

4 :
A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?

6 :
A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?

7 :
The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

8 :
The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

9 :
Restricted activity is prescribed for a client with Crohn's disease. The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?

10 :
The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?