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1. A client with chronic kidney disease (CKD) has a
serum potassium level of 6.8 mEq/L. Which
intervention should the nurse implement first?
A. Administer oral sodium polystyrene sulfonate.
B. Prepare the client for emergent hemodialysis.
C. Assess the client's electrocardiogram (ECG)
rhythm.
D. Administer intravenous calcium gluconate.
Correct Answer: C
,Rationale: The priority action is to assess the ECG
for tall peaked T waves and other dysrhythmias, as
hyperkalemia can cause fatal cardiac arrhythmias.
While all options are interventions for
hyperkalemia, assessment is the first step in the
nursing process and safety priority. Calcium
gluconate stabilizes the cardiac membrane but
should be given after ECG assessment;
hemodialysis is the definitive treatment but is not
the first action.
2. A postpartum client who is Rh-negative and has a
Rh-positive infant is prescribed Rh(D) immune
globulin. The nurse explains that this medication
prevents which complication in a future pregnancy?
A. Hemolytic disease of the newborn.
B. Neonatal jaundice.
C. Maternal thrombocytopenia.
D. Fetal growth restriction.
Correct Answer: A
Rationale: Rh(D) immune globulin prevents
maternal sensitization by destroying fetal Rh-
positive erythrocytes that have entered the
,maternal circulation. This prevents the mother
from producing anti-Rh antibodies, which could
cross the placenta in a subsequent pregnancy and
cause hemolytic disease of the newborn
(erythroblastosis fetalis).
3. A nurse is caring for a client with severe
preeclampsia receiving a continuous infusion of
magnesium sulfate. Which finding indicates
magnesium toxicity?
A. Respiratory rate of 14 breaths per minute.
B. Urinary output of 40 mL per hour.
C. Patellar reflex of 2+.
D. Serum magnesium level of 9.0 mg/dL.
Correct Answer: D
Rationale: The therapeutic range for magnesium
sulfate is 4 to 7 mg/dL. A level of 9.0 mg/dL
indicates toxicity. Signs of toxicity include loss of
deep tendon reflexes (hyporeflexia or areflexia),
respiratory depression (less than 12 breaths/min),
and oliguria (less than 30 mL/hr). The other
options are within normal or acceptable
parameters.
, 4. A client with heart failure is prescribed
furosemide and digoxin. Which laboratory value is
most important for the nurse to monitor?
A. Serum sodium.
B. Serum potassium.
C. Serum calcium.
D. Serum magnesium.
Correct Answer: B
Rationale: Furosemide is a loop diuretic that
causes potassium loss. Hypokalemia increases the
risk of digoxin toxicity by enhancing the effects of
digoxin on the myocardium. Monitoring serum
potassium is essential to prevent serious
dysrhythmias. While other electrolytes are
important, potassium is the most critical in this
combination therapy.
5. A client is admitted with acute pancreatitis.
Which laboratory finding is most specific for this
diagnosis?
A. Elevated serum amylase.
B. Elevated serum lipase.
C. Elevated white blood cell count.