a nurse is caring for a client who has hypertension and a potassium level of 68 meql which of the following actions should the nurse take
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form B

1. A client has hypertension and a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Obtaining a 12-lead ECG is crucial in this situation to assess cardiac function due to the elevated potassium level. High potassium levels can lead to dangerous arrhythmias, and an ECG helps in detecting any cardiac abnormalities. Choices A, C, and D are incorrect. Suggesting a salt substitute can further elevate the client's potassium levels. Checking serum sodium levels is not the priority when dealing with high potassium levels. Advising the client to add citrus juices and bananas, which are high in potassium, would worsen the situation.

2. A healthcare provider is reviewing the medical record of a client who has a new prescription for cimetidine. Which of the following laboratory findings should the healthcare provider identify as the priority to report to the provider?

Correct answer: C

Rationale: An elevated AST level is indicative of liver damage, which is the priority finding to report to the provider when administering cimetidine. Elevated liver enzymes can be a sign of liver toxicity or damage. Monitoring liver function is crucial when using cimetidine, as it can sometimes lead to hepatotoxicity. The other laboratory findings are within normal ranges and not directly associated with cimetidine administration.

3. A health care provider asks the nurse to administer a medication with a dosage significantly higher than usual. What is the nurse's first action?

Correct answer: B

Rationale: When a health care provider orders a medication with a dosage significantly higher than usual, the nurse's initial action should be to question the provider and verify the dose. This is crucial to ensure patient safety and prevent medication errors. Administering the medication as ordered (Choice A) without clarification could potentially harm the patient if there was an error in the prescription. Administering half the dosage as a precaution (Choice C) is not a safe practice as it deviates from the prescribed order. Refusing to administer the medication without clarification (Choice D) is important, but the first step should be to seek clarification from the provider to prevent any unnecessary delays in patient care.

4. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding indicates the condition is worsening?

Correct answer: A

Rationale: The correct answer is A: Increased shortness of breath. In COPD, worsening symptoms often include increased shortness of breath due to impaired lung function. This indicates a decline in respiratory status and the need for prompt intervention. Choice B, decreased wheezing, is not indicative of worsening COPD as it could suggest better airflow. Choice C, productive cough with green sputum, may indicate an infection but not necessarily worsening COPD. Choice D, a slight increase in fatigue, is non-specific and may not directly correlate with the worsening of COPD.

5. A nurse is preparing to administer ampicillin 500 mg IV bolus every 6 hours. Available is ampicillin 500 mg in 50 mL dextrose 5% in water (D5W) to infuse over 20 minutes. The nurse should set the IV pump to deliver how many mL/hr?

Correct answer: B

Rationale: To infuse 50 mL over 20 minutes, the pump should be set to 150 mL/hr. This calculation ensures the correct rate for the infusion of the medication. Choices A, C, and D are incorrect as they do not align with the correct calculation based on the given information.

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