A client who received 6 units of packed red blood cells 3 days ago for a lower gastrointestinal (GI) bleed is now displaying signs of shortness of breath with occasional stridor and is reporting muscle cramping.

Reference Range:
Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
Magnesium [Adult: 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L)]
Calcium [9 to 10.5 mg/dL (2.3 to 2.6 mmol/L)]
Sodium (136 to 145 mEq/L (136 to 145 mmol/L)]

Which serum laboratory value should the nurse immediately report to the healthcare provider?

Potassium 4.7 mEq/L (4.70 mmol/L).

Magnesium 2.1 mEq/L (0.86 mmol/L).

Calcium 6.5 mg/dL (1.63 mmol/L).

Sodium 135 mEq/L (135 mmol/L).

Answer and Explanation

The Correct Answer is C

Choice A reason: Potassium 4.7 mEq/L (4.70 mmol/L) is within the normal reference range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Potassium is an electrolyte that helps regulate the balance of fluids and acids in the body, as well as the function of nerves and muscles. A high potassium level (hyperkalemia) can cause muscle weakness, irregular heartbeat, and cardiac arrest. A low potassium level (hypokalemia) can cause muscle cramps, fatigue, and arrhythmias.

Choice B reason: Magnesium 2.1 mEq/L (0.86 mmol/L) is within the normal reference range of 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Magnesium is an electrolyte that helps regulate the activity of enzymes, muscles, and nerves, as well as the balance of calcium and potassium in the body. A high magnesium level (hypermagnesemia) can cause nausea, vomiting, flushing, muscle weakness, and respiratory depression. A low magnesium level (hypomagnesemia) can cause muscle twitching, tremors, seizures, and cardiac arrhythmias.

Choice C reason: Calcium 6.5 mg/dL (1.63 mmol/L) is below the normal reference range of 9 to 10.5 mg/dL (2.3 to 2.6 mmol/L). Calcium is an electrolyte that helps regulate the function of muscles, nerves, bones, and blood clotting. A high calcium level (hypercalcemia) can cause nausea, vomiting, constipation, confusion, kidney stones, and bone pain. A low calcium level (hypocalcemia) can cause muscle spasms, cramps, tingling, numbness, and stridor (a high-pitched sound when breathing). **This is a critical value that should be immediately reported to the healthcare provider**, as it can indicate a serious condition such as acute pancreatitis, sepsis, or massive blood transfusion.

Choice D reason: Sodium 135 mEq/L (135 mmol/L) is slightly below the normal reference range of 136 to 145 mEq/L (136 to 145 mmol/L). Sodium is an electrolyte that helps regulate the balance of fluids and acids in the body, as well as the function of nerves and muscles. A high sodium level (hypernatremia) can cause thirst, dry mouth, confusion, seizures, and coma. A low sodium level (hyponatremia) can cause headache, nausea, vomiting, fatigue, muscle weakness, and confusion.

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Correct Answer is C

Explanation

Choice A reason: Redness and edema noted at the incision site are signs of inflammation, which are normal in the early stages of wound healing. The nurse should monitor the site for signs of infection, such as purulent drainage, increased pain, or fever.

Choice B reason: Apical heart rate of 100 to 110 beats/minute is a sign of tachycardia, which may be caused by pain, anxiety, dehydration, or blood loss. The nurse should assess the client's vital signs, fluid status, and hemoglobin level, and administer pain medication as prescribed.

Choice C reason: High-pitched sound heard upon inspiration is a sign of stridor, which is a life-threatening emergency that indicates airway obstruction. The nurse should call for help, administer oxygen, and prepare for intubation or tracheostomy.

Choice D reason: Pain rating of 8 on a scale of 0 to 10 is a sign of severe pain, which may impair the client's recovery and increase the risk of complications. The nurse should administer pain medication as prescribed and use non-pharmacological methods to relieve pain, such as positioning, distraction, or relaxation techniques.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"D","dropdown-group-4":"A"}

Explanation

The client has inhaled smoke, which can cause respiratory problemssuch as airway obstruction, bronchospasm, and pulmonary edema. The client also has initial fluid shifts, which can lead to electrolyte imbalancesuch as hyponatremia, hyperkalemia, and metabolic acidosis.

Choice A: inhaled smoke - respiratory problems

This is a correct choice. Inhaled smoke can damage the respiratory system by causing inflammation, edema, and carbon monoxide poisoning.

Choice B: initial fluid shifts - electrolyte imbalance

This is a correct choice. Initial fluid shifts occur when fluid moves from the intravascular space to the interstitial space due to increased capillary permeability. This can result in electrolyte imbalance such as low sodium, high potassium, and low bicarbonate levels.

Choice C: increased cardiac output - high blood sodium levels

This is an incorrect choice. Increased cardiac output is not a condition that occurs in burn patients. High blood sodium levels are not a common finding in burn patients either. High blood sodium levels can occur due to dehydration or excessive sodium intake.

Choice D: decreased catecholamines - hypometabolism

This is an incorrect choice. Decreased catecholamines are not a finding in burn patients. Catecholamines are hormones that increase heart rate, blood pressure, and metabolism in response to stress. Burn patients have increased catecholamines due to pain and tissue injury. Hypometabolism is also not a condition that occurs in burn patients. Hypometabolism is a state of low metabolic rate that can occur due to starvation, hypothyroidism, or hypothermia. Burn patients have increased metabolism due to increased energy demands for wound healing and thermoregulation.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

Correct Answer is C

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"D","dropdown-group-4":"A"}

Explanation

A client who had a biliopancreatic diversion procedure (BPD) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?

An older adult client with symptoms of osteoarthritis asks the nurse which form of exercise would be most beneficial. Which is the best response by the nurse?

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

Exhibits The nurse is reviewing the physician orders. Which of the following physician’s orders requires priority attention from the nurse? Select all that apply.

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?