Answer to Question 1
Correct Answer: 4
Rationale 1: Muscle fatigue, not pain, is associated with hypernatremia.
Rationale 2: The daily weight is not the nurse's highest priority for this client.
Rationale 3: Thirst is a normal mechanism when a client's serum osmolality increases.
Rationale 4: Hypernatremia can cause increased intracranial pressure. This should be reported to the health care provider immediately.
Global Rationale: Hypernatremia can cause increased intracranial pressure. This should be reported to the health care provider immediately. Muscle fatigue, not pain, is associated with hypernatremia. The daily weight is not the nurse's highest priority for this client. Thirst is a normal mechanism when a client's serum osmolality increases.
Answer to Question 2
Correct Answer: 2
Rationale 1: The respiratory system is not the body system most profoundly affected by potassium imbalance.
Rationale 2: This value represents hyperkalemia. Both hyper- and hypokalemia are associated with fatal dysrhythmias and serious neuromuscular disorders.
Rationale 3: The hematological system is not the body system most profoundly affected by potassium imbalance.
Rationale 4: The genitourinary system is not the body system most profoundly affected by potassium imbalance.
Global Rationale: This value represents hyperkalemia. Both hyper- and hypokalemia are associated with fatal dysrhythmias and serious neuromuscular disorders. The respiratory system, hematological system, and genitourinary system are not the most profoundly affected by potassium imbalance.
Client position when assessing jugular vein distention.
The nurse applies a pulse oximeter sensor on the client’s finger.
Nursing assessment questions
Clinician performing capillary refill assessment.
The level of emissions from transport in the United States is twice as high as the global average
Ramey's study, children from poverty-level families IQ experiment