a client with heart failure is prescribed furosemide the nurse notes that the clients potassium level is 31 meql what is the nurses priority action
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam Capstone

1. A client with heart failure is prescribed furosemide. The nurse notes that the client's potassium level is 3.1 mEq/L. What is the nurse's priority action?

Correct answer: A

Rationale: A potassium level of 3.1 mEq/L is considered low, indicating hypokalemia. Administering a potassium supplement is the nurse's priority action to prevent complications such as cardiac arrhythmias associated with low potassium levels. Encouraging the client to eat potassium-rich foods is beneficial in the long term but may not rapidly correct the low potassium level. Holding the next dose of furosemide may worsen the client's heart failure symptoms. Increasing the client's fluid intake is not the priority action in this situation; addressing the low potassium level takes precedence to prevent potential serious complications.

2. A client with type 2 diabetes mellitus arrives at the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation?

Correct answer: B

Rationale: Numb fingertips may suggest neuropathy, a common complication of diabetes that may indicate a worsening condition. Episodes of weakness and palpitations, combined with neuropathy symptoms, could also suggest hypoglycemia or poor glycemic control, requiring further investigation. The other choices are less likely to be directly related to the client's current symptoms. While a history of hypertension is a common comorbidity in clients with diabetes, it may not directly explain the reported weakness and palpitations. Reduced deep tendon reflexes are more indicative of certain neurological conditions rather than acute emerging situations related to the client's current symptoms. An elevated fasting blood glucose level is expected in a client with type 2 diabetes and may not be the primary indicator of an emerging situation in this context.

3. A client is scheduled for a colonoscopy. Which preparation is the most important for the nurse to implement?

Correct answer: D

Rationale: The correct answer is to verify that the client has completed the bowel preparation. This step is crucial to ensure the colon is clear for accurate visualization during the procedure. Administering an enema before the procedure may not always be necessary and can be uncomfortable for the client. Ensuring the client is NPO after midnight is important, but verifying bowel preparation takes precedence. Encouraging the client to drink clear liquids is a part of the preparation process but not the most critical step compared to verifying completion of bowel preparation.

4. After placing a stethoscope to auscultate S1 and S2 heart sounds, what should the nurse do to check for an S3 heart sound?

Correct answer: B

Rationale: To assess for an S3 heart sound, the nurse should listen with the bell of the stethoscope. An S3 heart sound is often low-pitched and best heard with the bell. Choice A is incorrect because switching to the diaphragm is not ideal for detecting low-pitched sounds like an S3. Choice C is incorrect as the S3 heart sound is best heard over the apex of the heart, not the aortic area. Choice D is incorrect because moving to the apical area is appropriate, but the nurse should specifically use the bell of the stethoscope to listen for S3 sounds.

5. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?

Correct answer: D

Rationale: Performing nostril and mouth care is a non-invasive task that can be safely delegated to an unlicensed assistive personnel (UAP). Observing the type and amount of nasogastric tube drainage requires assessment skills and understanding of potential complications, making it more appropriate for a licensed healthcare professional. Monitoring the client for nausea or other complications involves interpreting client responses and identifying adverse reactions, which also requires a licensed healthcare professional. Irrigating the nasogastric tube with the ordered solution involves a procedure that can impact the client's condition and should be performed by a licensed healthcare professional to prevent complications.

Similar Questions

The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to
A young adult visits the clinic reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan?
A client reports that the skin around the edges of a wound is red and swollen. What is the nurse's priority intervention?
A child is brought to the emergency department after ingesting an unknown quantity of acetaminophen. What is the most important action for the nurse to take?
The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving anticoagulant therapy. Which intervention should the nurse implement to prevent complications?

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses