A client with intestinal obstruction has a nasogastric tube to low intermittent suction and is receiving an intravenous (IV) infusion of lactated Ringer's at 100 mL/hour.
Which finding is most important for the nurse to report to the healthcare provider? Reference Range: Potassium (3.5 to 5 mEq/L (3.5 to 5 mmol/L).

24-hour intake at the current infusion rate.

Serum potassium level of 3.1 mEq/L (3.1 mmol/L).

Gastric output of 900 mL in the last 24 hours.

Increased blood urea nitrogen (BUN).

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Reporting the 24-hour intake at the current infusion rate is not the most important finding to report to the healthcare provider in this case. It is essential to monitor intake and output, but a single report of the 24-hour intake is not as critical as other findings.

Choice B rationale:

Reporting a serum potassium level of 3.1 mEq/L (3.1 mmol/L) is the most important finding to report to the healthcare provider. The patient's potassium level is below the normal range, indicating hypokalemia. Hypokalemia can have serious cardiac and neuromuscular effects, including arrhythmias and muscle weakness. Prompt intervention, such as potassium supplementation or adjustment of IV fluids, is necessary to address this potentially life-threatening condition.

Choice C rationale:

Reporting a gastric output of 900 mL in the last 24 hours is significant and should be reported to the healthcare provider, but it is not as urgent as the low potassium level. Gastric output should be monitored to assess for signs of improvement or worsening, but hypokalemia takes precedence due to its immediate health risks.

Choice D rationale:

Reporting an increased blood urea nitrogen (BUN) is important for the overall assessment of the patient's renal function but is not the most critical finding in this scenario. The low potassium level is a more immediate concern and requires immediate attention.

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Correct Answer is C

Explanation

The correct answer is choice C: Increase rate of ventilation.

Choice A rationale:

Decreasing expiratory flow time would not directly address the elevated PaCO2 levels. This intervention is more related to managing expiratory phase issues rather than correcting respiratory acidosis.

Choice B rationale:

Decreasing expiratory pressure might help with certain ventilation issues, but it does not specifically target the elevated PaCO2 and resulting acidosis.

Choice C rationale:

Increasing the rate of ventilation helps to blow off more CO2, thereby reducing PaCO2 levels and correcting the respiratory acidosis indicated by the pH of 7.26 and PaCO2 of 68 mm Hg.

Choice D rationale:

Increasing the ventilator tidal volume could also help reduce PaCO2 by increasing the amount of air exchanged with each breath. However, increasing the rate of ventilation is generally a more immediate and effective intervention for acute respiratory acidosis.

A. Use a peak flow meter to assess the respiratory status. B. Administer a stat dose of corticosteroids. C. Document the normal finding in the client's health record. D. Repeat a dose of the client's rescue drug.

Correct Answer is A

Explanation

Choice A rationale:

Use a peak flow meter to assess the respiratory status. Assessing the client's respiratory status using a peak flow meter is the most appropriate next action after administering albuterol, a bronchodilator. It helps determine the client's lung function and response to the medication. This information guides further interventions and treatment decisions.

Choice B rationale:

Administer a stat dose of corticosteroids. Administering corticosteroids may be indicated in some cases of respiratory distress or exacerbation of asthma. However, it should not be the immediate next step after albuterol administration. Assessing the client's response to albuterol through lung function testing (peak flow) is essential before deciding on additional medications.

Choice C rationale:

Document the normal finding in the client's health record. Documenting normal findings is important for maintaining accurate medical records, but in this case, it is premature. The nurse should first assess the client's response to albuterol and ensure that the respiratory status is indeed normal before documenting the findings.

Choice D rationale:

Repeat a dose of the client's rescue drug. Administering another dose of the rescue drug (albuterol) without assessing the client's response and lung function would not be the most appropriate action. It is essential to determine whether the initial dose was effective before considering additional doses or alternative treatments.

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Naxlex Comprehensive Predictor Exams

A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement?

Correct Answer is C

Explanation

After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment?

Correct Answer is A

Explanation

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