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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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Applying restraints should be a last resort and only if less restrictive measures have failed. It is also essential to follow legal and ethical guidelines regarding the use of restraints.

B. Calling the family to stay with the client may provide temporary comfort but does not directly address safety concerns or the underlying cause of restlessness and confusion.

C. Sedating the client might not be appropriate without first assessing the cause of the restlessness and confusion. Medications should be used cautiously and based on a thorough evaluation.

D. Moving the client closer to the nurses' station allows for more frequent monitoring and quick intervention if needed, addressing the immediate safety concern of restlessness and confusion. This measure helps ensure the client’s safety while further assessment and intervention are being planned.

A. An urge to void despite having an indwelling urinary catheter B. Output of burgundy colored urine C. Pulse rate of 88/min D. Oral temperature of 38.2° C (100.76° F)

Correct Answer is B

Explanation

A. An urge to void despite an indwelling catheter may be a normal postoperative sensation due to bladder irritation, but it is not a clear indication of a complication.
B. Output of burgundy colored urine can indicate significant bleeding or a complication such as hemorrhage, which requires immediate attention.
C. A pulse rate of 88/min is within normal limits and does not suggest a postoperative complication.
D. An oral temperature of 38.2° C (100.76° F) is slightly elevated but not uncommon immediately after surgery; it may be monitored but does not immediately indicate a serious complication.

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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.

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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.