a patients serum potassium level is 22 meql which nursing action is the highest priority for this patient
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Nursing Elites

HESI LPN

HESI Leadership and Management Quizlet

1. A patient's serum potassium level is 2.2 mEq/L. Which nursing action is the highest priority for this patient?

Correct answer: B

Rationale: The correct answer is to initiate cardiac monitoring. Severe hypokalemia can lead to life-threatening arrhythmias, making cardiac monitoring the priority to detect and manage any cardiac complications. Starting oxygen, seizure precautions, or bed rest are not the immediate priority actions for severe hypokalemia.

2. What is idiopathic thrombocytopenia purpura?

Correct answer: C

Rationale: Idiopathic thrombocytopenic purpura is a bleeding disorder characterized by a low number of platelets in the blood. This condition is not highly similar to disseminated intravascular coagulation (DIC), which involves abnormal clotting throughout the body (coagulation), leading to depletion of platelets. Choice B is incorrect because idiopathic thrombocytopenic purpura is actually characterized by a decrease in platelet count, not an overproduction. While immune system-boosting medications may be used in some cases, the primary treatment for idiopathic thrombocytopenic purpura focuses on increasing platelet counts or managing symptoms.

3. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct answer: A

Rationale: The correct action for the nurse to take first is to remove the restraints from the client's wrists. Restraints should not be applied without a prescription due to the risk of harm to the client. Removing the restraints promptly is a priority to ensure the client's safety. Reviewing nonrestraint alternatives, speaking with the AP, and informing the unit manager can follow after ensuring the client's immediate safety by removing the restraints.

4. Which of the following joints normally allows 360-degree circumflexion?

Correct answer: B

Rationale: The correct answer is B: The shoulder. The shoulder joint is a ball-and-socket joint that allows for a wide range of motion, including 360-degree circumflexion. This joint provides flexibility and mobility in various directions. Choice A, the knee joint, primarily allows flexion and extension but does not have a 360-degree circumflexion. Choice C, the elbow joint, is a hinge joint that permits flexion and extension but not circumflexion. Choice D, the fingertips, do not form a specific joint that allows circumflexion; rather, they have joints that enable bending and straightening movements.

5. A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?

Correct answer: C

Rationale: A nurse who floated from a medical-surgical unit would be appropriate to care for a client who is 1 day postoperative following a Cesarean section and has a PCA pump. This client requires monitoring of the postoperative incision site, pain management through the PCA pump, and assessment for any signs of complications related to the surgery. Assigning this client to an RN with experience in postoperative care aligns with providing specialized and appropriate care. Choices A, B, and D involve conditions or procedures specific to obstetrics that would be better managed by a nurse with obstetrical experience, making them incorrect choices for the floated RN.

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