a patient has a serum calcium level of 70 meql which assessment finding is most important for the nurse to report to the health care provider
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Nursing Elites

HESI RN

Adult Health 2 HESI Quizlet

1. A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

Correct answer: A

Rationale: The correct answer is A - 'The patient is experiencing laryngeal stridor.' Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient’s calcium level to prevent a life-threatening situation. Choices B, C, and D are also symptoms of hypocalcemia, but laryngeal stridor takes precedence due to its potential to quickly progress to a critical condition.

2. At 01:00 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

Correct answer: A

Rationale: The client has a plan to read until feeling sleepy, indicating an intention to sleep. Therefore, offering a PRN sedative-hypnotic (C) is unnecessary, especially since it is a stronger sleep aid. Option (D) is not needed as the client already has a plan to address his sleeplessness. Assessing the surgical dressing (B) is not relevant to the client's immediate need for sleep. Leaving the room and closing the door (A) is the appropriate action to provide a conducive environment for the client to rest.

3. A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?

Correct answer: B

Rationale: In this situation, where there is a conflict between the client's significant other and estranged husband, the most appropriate intervention is to request a consultation with the ethics committee for resolution. This ensures that an impartial body can assess the situation, consider the rights and preferences of all parties involved, and provide guidance on how to proceed in a fair and ethical manner. Obtaining a court order (Choice A) may be a legal option but should be considered after exhausting other conflict resolution methods. Involving security (Choice C) may escalate the situation and should only be considered if there is a risk of harm. Discussing boundaries with the client (Choice D) is important but may not immediately address the current conflict between the significant other and the husband.

4. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

Correct answer: A

Rationale: The correct answer is A: "Blood pressure is 90/40 mm Hg." A low blood pressure reading of 90/40 mm Hg indicates that the patient may be developing hypovolemic shock due to intravascular fluid loss from the burn injury. This finding is of utmost concern as it suggests systemic hypoperfusion, requiring immediate intervention to prevent complications. Choices B, C, and D also indicate signs of dehydration and the need to increase fluid intake; however, they are not as urgent as addressing the hypotension and potential shock presented in choice A.

5. A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

Correct answer: C

Rationale: Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

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