In a client with chronic kidney disease having a serum potassium level of 6.5 mEq/L, which assessment is the most critical for the nurse to perform?

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Question 1 of 5

In a client with chronic kidney disease having a serum potassium level of 6.5 mEq/L, which assessment is the most critical for the nurse to perform?

Correct Answer: B

Rationale: Corrected Rationale: Assessing cardiac status is crucial in hyperkalemia as high potassium levels can result in life-threatening arrhythmias. Monitoring the heart rhythm and ECG findings is essential to prevent cardiac complications. Neurological status, respiratory status, and gastrointestinal status are important assessments too, but in the context of hyperkalemia, cardiac status takes precedence due to the immediate risk of cardiac arrhythmias.

Question 2 of 5

The healthcare provider is assessing a client who has just returned from surgery. Which of these findings requires the most immediate attention?

Correct Answer: C

Rationale: A temperature of 99.5 degrees Fahrenheit is slightly elevated but not immediately critical. In a postoperative patient, an elevated temperature could indicate an infection, which requires prompt attention to prevent complications. The respiratory rate, blood pressure, and heart rate within normal ranges are important to monitor but do not indicate an immediate need for intervention as an elevated temperature does.

Question 3 of 5

A client with a history of deep vein thrombosis (DVT) is being treated with anticoagulants. Which of these findings is most concerning to the nurse?

Correct Answer: C

Rationale: The correct answer is C because pain and swelling in the calf can indicate a new or worsening DVT, requiring immediate attention. Bruising on the arms and legs may be a common side effect of anticoagulants but is not as concerning as a potential DVT. Severe headache may indicate other conditions like a migraine or hypertension and is not directly related to DVT. Increased urination is not typically associated with DVT and may point towards other health issues like diabetes or urinary tract infections.

Question 4 of 5

A client is being treated for tuberculosis (TB). Which of these statements indicates the client understands the transmission of TB?

Correct Answer: A

Rationale: The correct answer is A because wearing a mask in public can help prevent the spread of TB to others. Choice B is incorrect as taking medication as prescribed helps in treating the infection within the individual but does not directly prevent spreading it to others. Choice C is important for respiratory hygiene but may not be sufficient to prevent transmission. Choice D, isolation until treatment is complete, is crucial for preventing the spread but is not specifically about understanding transmission.

Question 5 of 5

A client with a history of coronary artery disease is admitted with chest pain. Which of these findings would be most concerning to the nurse?

Correct Answer: B

Rationale: The correct answer is B. A respiratory rate of 20 breaths per minute may indicate respiratory distress in a client with chest pain. In a client with a history of coronary artery disease presenting with chest pain, signs of respiratory distress can be an alarming finding. Blood pressure within the normal range (130/80 mm Hg), heart rate of 72 beats per minute, and a temperature of 98.6 degrees Fahrenheit are generally considered within normal limits and may not be as concerning in this context.

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