A nurse is assisting in the care of a client who has preeclampsia. Which of the following findings should the nurse report to an RN immediately?

Rationale:

A. New onset of hearing loss: Hearing loss is not a typical adverse effect of 0.9% sodium chloride infusion. It may occur with high-dose loop diuretics like furosemide but is unrelated to isotonic fluid administration or hyperparathyroidism management.

B. Kussmaul respirations: These are deep, rapid respirations seen in metabolic acidosis, particularly diabetic ketoacidosis. They are not associated with isotonic fluid infusion or calcium disturbances in hyperparathyroidism.

C. Hyperthermia: Elevated body temperature is not linked to 0.9% sodium chloride infusion. Hyperthermia may occur with infections or neurologic injury, but not as a direct consequence of isotonic fluid therapy.

D. Chvostek's sign: Chvostek's sign is a clinical indicator of hypocalcemia, which can occur as an adverse effect of 0.9% sodium chloride infusion in clients with hyperparathyroidism. Large volumes of saline increase calcium excretion, potentially leading to low serum calcium levels.

Rationale:

A. A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report: This is an appropriate and necessary exchange of client information for continuity of care. It supports safe, effective handoff communication between nurses involved in the client’s treatment.

B. A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care: This violates the Health Insurance Portability and Accountability Act (HIPAA) by sharing protected health information with someone not directly involved in the client’s care, regardless of location or setting.

C. A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for: This is an expected and proper part of nursing responsibilities. Accurate and timely documentation in the EMR is essential for effective communication and patient safety.

D. A nursing colleague printing material that does not obtain identifiable information from a client's electronic medical record (EMR) for professional use: If no identifiable health information is included, printing such materials for professional reference or education is acceptable and does not violate confidentiality rules.