ADULT HEALTH lll EXAM 1-4 & FINAL EXAM LATEST VERSIONS 2023-2024 REAL EXAM QUESTIONS AND CORRECT ANSWERS|GRADED A+

Feedback: When a client is intubated with a endotracheal tube for mechanical ventilation, the nurse should immediately assess for chest expansion symmetry and auscultate breath sounds bilaterally. The client will have a chest radiograph to confirm placement, but that is not the immediate priority. Repositioning the client and assessing for aspiration are important to prevent complications, but

46. The nurse is caring for a client who was admitted with diabetic ketoacidosis (DKA) and has a serum potassium level of 2.9 mEq/L. Which of the following actions, if prescribed by the health care provider, should the nurse take first?
a. Place the client on a cardiac monitor.
b. Administer regular insulin intravenously (IV) at 20 units/hr.
c. Administer intravenous (IV) potassium supplements.
d. Obtain urine glucose and ketone levels.

Feedback: Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Since potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring, since insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the patient’s care. Lewis 2017, pgs. 282-283akcd

47. The nurse received change of shift report about assigned clients. Which of the following clients should the nurse assess first?
The client with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep
tendon reflexes.
a.
b. The client with serum potassium level 5.0 mEq/L who is reporting abdominal cramping.
c. The client with serum sodium level 145 mEq/L who reports dry mouth and is asking for water.
d. The client with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium- phosphate precipitates.

Feedback: The client with low magnesium needs to be seen first because hypomagnesemia can lead to cardiac dysrhythmias. The client with a high phosphorus is just barely high and has manifestations that are expected and not life threatening. The client with a high normal potassium level is experiencing expected symptoms of abdominal cramping and also does not have life-threatening symptoms. Finally, the client whose sodium is 145 is within normal limits and so would not be the priority. Lewis 2017, p. 286k, 279b,280-281a, 285d

48. A client is admitted to the intensive care unit (ICU) after a motor vehicle collision (MVC) in which the client received blunt trauma to the chest. The client is in acute respiratory failure and is intubated and minimally sedated. Which of the following should the ICU nurse monitor when caring for the client? Select all that apply.
a. ability to communicate verbally
b. respiratory system
c. oral intake
arterial blood gases (ABGs)
vital signs (VS)
d.
e.