Page 1888 - Saunders Comprehensive Review For NCLEX-RN

potassium level of 7.0 is elevated. The client with hyperkalemia is at risk of
developing cardiac dysrhythmias and cardiac arrest. Because of this, the client
should be placed on a cardiac monitor. The nurse should notify the PHCP and also
review medications to determine whether any contain potassium or are potassium
retaining. The client does not need to be put on NPO status. Fluid intake is not
increased because it contributes to fluid overload and would not affect the serum
potassium level significantly.
Test-Taking Strategy: Note the strategic word, priority. First, note that the
potassium level is significantly elevated to select options 1 and 4. Also, use the ABCs
—airway, breathing, and circulation—to select option 2.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Adult Health: Renal and Urinary
Health Problem: Adult Health: Renal and Urinary: Acute kidney injury
Priority Concepts: Clinical Judgment; Fluids and Electrolytes
Reference: Ignatavicius, Workman, Rebar (2018), pp. 178-179, 192.

642. Answer: 1, 3, 4

Rationale: If the client experiences air embolus during hemodialysis, the nurse
should terminate dialysis immediately, position the client so the air embolus is in the
right side of the heart, notify the PHCP and Rapid Response Team, and administer
oxygen as needed. Slowing the dialysis treatment or giving an intravenous bolus
will not correct the air embolism or prevent complications.
Test-Taking Strategy: Note the strategic word, priority. Recall that air embolism is
an emergency situation that affects the cardiopulmonary system suddenly and
profoundly. Select the options that deal with the problem, supply oxygen, and get
needed assistance.
Level of Cognitive Ability: Synthesizing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Renal and Urinary: Chronic kidney disease
Priority Concepts: Clinical Judgment; Gas Exchange
Reference: Ignatavicius, Workman, Rebar (2018), p. 214.

643. Answer: 3

Rationale: Bladder trauma or injury should be considered or suspected in the
client with low abdominal pain and hematuria. Glomerulonephritis and
pyelonephritis would be accompanied by fever and are thus not applicable to the
client described in this question. Renal cancer would not cause pain that is felt in the
low abdomen; rather, the pain would be in the flank area.
Test-Taking Strategy: Note the strategic word, next. Eliminate options 1 and 2
because they are comparable or alike, knowing that any inflammatory disease or
infection is accompanied by fever. Because this client is afebrile, these are not

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