A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain.
Exhibits
Select the top 4 client findings that requires immediate follow up.
Potassium 7.0 mEq/L (3.5 to 5 mEq/L)
WBC count 17,000/mm3 (Normal Finding: 5,000 to 10,000/mm3)
Crackles throughout lungs
Creatinine 3.0 mg/dL (0.5 to 1.3 mg/dL)
Abdomen rigid with decreased bowel sounds
Glucose 250 mg/dL
No dialysis for 24 hr
Hemoglobin 10 g/dL (12 to 18 g/dL) Nausea
Correct Answer : A,B,C,H
A. Potassium 7.0 mEq/L (3.5 to 5 mEq/L): Elevated potassium levels (hyperkalemia) can cause life-threatening cardiac arrhythmias and are especially concerning in clients with chronic kidney disease who are at risk of renal complications. Immediate follow-up is crucial to prevent severe cardiac effects.
B. WBC count 17,000/mm³ (Normal Finding: 5,000 to 10,000/mm³): An elevated WBC count indicates an infection or inflammation, which is concerning given the client’s symptoms and temperature. This finding requires immediate follow-up to address potential infection.
C. Crackles throughout lungs: Crackles may indicate fluid overload or pulmonary edema, particularly in clients with chronic kidney disease. This could be a sign of worsening renal function or heart failure, which requires prompt attention.
H. No dialysis for 24 hr: Missing dialysis sessions in a client with stage IV chronic kidney disease can lead to dangerous fluid and electrolyte imbalances. This finding requires immediate action to prevent complications related to renal failure.
Explanation of Incorrect Options:
E. Creatinine 3.0 mg/dL (0.5 to 1.3 mg/dL): While elevated creatinine levels are concerning, the client’s history of chronic kidney disease means this level is expected to be higher. However, it is not as immediately critical as the other findings.
F. Abdomen rigid with decreased bowel sounds: This may suggest abdominal complications but is not as immediately critical as issues related to hyperkalemia or infection.
G. Glucose 250 mg/dL: Elevated glucose levels are concerning but less immediately critical compared to severe electrolyte imbalances and potential infections.
H. Hemoglobin 10 g/dL (12 to 18 g/dL): Anemia is a concern but is not as urgent as the immediate risks posed by elevated potassium, signs of infection, or missed dialysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tucking the chin when swallowing can help reduce the risk of aspiration in clients with certain conditions, but after a total laryngectomy, clients are at increased risk for aspiration due to altered anatomy and should have thickened liquids to minimize this risk.
B. Clients who have undergone a total laryngectomy may have difficulties with swallowing and are at risk of aspiration. It is not accurate to say they will have no trouble swallowing fluids without proper assessment and adaptation.
C. Adding a thickener to liquids is a recommended intervention to reduce the risk of aspiration in clients who have had a laryngectomy, as thickened fluids are less likely to be aspirated into the lungs compared to thin liquids.
D. Clients who have had a total laryngectomy are still at risk for choking or aspiration due to changes in their swallowing mechanics and altered anatomy. It is important to take preventive measures, such as thickening liquids.
Correct Answer is A
Explanation
A. Placing the client on their left side in Trendelenburg position (head down, feet up) helps trap any air in the right atrium and prevents it from entering the pulmonary circulation, reducing the risk of an air embolism affecting the lungs.
B. Replacing the infusion system does not address the immediate need to manage an air embolism. The primary intervention is positioning and monitoring.
C. Removing the catheter is not the initial priority. The focus should be on managing the air embolism and ensuring the client is in the correct position.
D. Preparing for chest tube insertion is not appropriate unless there is evidence of a pneumothorax or hemothorax. The immediate concern is managing the air embolism.
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