A nurse is admitting a 45-year-old male client who has type 1 diabetes mellitus in the emergency department.
Select the findings that require immediate attention.
Glasgow Coma Scale score
Client's self-monitoring of blood glucose
Bicarbonate level
Vaccess
Oxygen saturation
Blood pressure results
ECG findings
Sodium level
Correct Answer : A,C,F,G,H
Choice A rationale:
The Glasgow Coma Scale score has decreased from 14 to 12, indicating a decline in the client's level of consciousness. This finding requires immediate attention as it may signify worsening neurological status or an underlying condition such as metabolic disturbances, hypoxia, or intracranial pathology.
Choice C rationale:
The bicarbonate level is 13 mEq/L, which is significantly lower than the normal range of 21-28 mEq/L. This indicates metabolic acidosis, a condition where the blood is too acidic. It requires immediate intervention to prevent severe complications such as shock or organ failure.
Choice F rationale:
The client's blood pressure readings show hypotension with a supine blood pressure of 100/70 mm Hg and sitting blood pressure of 85/50 mm Hg. This suggests hemodynamic instability, which could be due to dehydration, sepsis, or other critical conditions requiring urgent treatment.
Choice G rationale:
The ECG findings indicate tachycardia with a prolonged PR interval, widened QRS complex, and peaked T waves. These are signs of hyperkalemia, a potentially life-threatening condition requiring immediate attention to prevent cardiac arrest.
Choice H rationale:
The sodium level is 152 mEq/L, which is higher than the normal range of 136-145 mEq/L, indicating hypernatremia. This electrolyte imbalance can lead to severe neurological symptoms and requires prompt correction to prevent complications such as seizures or coma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Respiratory alkalosis involves low carbon dioxide levels, which is not typical in COPD exacerbations.
Choice B rationale
Respiratory acidosis occurs due to impaired gas exchange and carbon dioxide retention in COPD.
Choice C rationale
Metabolic acidosis results from renal or metabolic issues, not primarily respiratory issues like in COPD.
Choice D rationale
Metabolic alkalosis involves high bicarbonate levels and is not typically associated with COPD exacerbations. .
Correct Answer is C
Explanation
Choice A rationale
Bubbling in the water seal chamber with exhalation indicates that air is still being removed from the pleural space, which is expected with a pneumothorax and is not a cause for immediate concern.
Choice B rationale
Eyelets not being visible indicate that the chest tube is properly placed within the pleural space, not an urgent issue.
Choice C rationale
Movement of the trachea towards the unaffected side is a sign of tension pneumothorax, which requires immediate intervention as it can compromise respiratory function.
Choice D rationale
Crepitus in the area above and surrounding the insertion site indicates subcutaneous emphysema, which can occur but does not necessitate immediate provider notification unless severe.
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