A nurse is caring for a client with a pressure injury. Which of the following should the nurse recognize as a priority in the plan of care?

A serum potassium level of 3.2 mEq/L indicates hypokalemia, which is a potential complication of inhibiting aldosterone secretion and release. Aldosterone plays a key role in potassium regulation in the body by promoting potassium excretion in the kidneys. When aldosterone secretion is inhibited, potassium excretion decreases, leading to an accumulation of potassium in the bloodstream and resulting in hypokalemia. Symptoms of hypokalemia may include muscle weakness, cramping, irregular heartbeat, and fatigue.

B. Urine output of 1,200 mL in the last 2 hours:

This option does not directly relate to complications of inhibiting aldosterone secretion. A urine output of 1,200 mL in the last 2 hours indicates adequate urine production, which is generally a positive sign. However, in the context of inhibiting aldosterone secretion, the nurse would be more concerned about decreased urine output due to potential renal effects.

C. Blood osmolality of 250 mOsm/kg (250 mmol/kg):

Blood osmolality within the normal range (usually around 275-295 mOsm/kg) is not directly associated with complications of inhibiting aldosterone secretion. Blood osmolality reflects the concentration of solutes in the blood and is regulated by various factors, including water balance, electrolyte levels, and hormonal regulation. Inhibiting aldosterone secretion primarily affects electrolyte balance rather than blood osmolality.

D. Urine output of 25 mL/hr:

A urine output of 25 mL/hr is considered low and may indicate decreased renal perfusion or impaired kidney function. Inhibiting aldosterone secretion can affect renal function and urine output, leading to decreased urine production. Reduced urine output can contribute to fluid and electrolyte imbalances and may be a concern in patients with inhibited aldosterone secretion.

E. Serum potassium level of 5.4 mEq/L:

A serum potassium level of 5.4 mEq/L indicates hyperkalemia, which is another potential complication of inhibiting aldosterone secretion. Aldosterone helps regulate potassium levels by promoting potassium excretion in the kidneys. When aldosterone secretion is inhibited, potassium excretion decreases, leading to an accumulation of potassium in the bloodstream and resulting in hyperkalemia. Symptoms of hyperkalemia may include muscle weakness, irregular heartbeat, nausea, and numbness or tingling.

1. A. How many people live in your home?

   This question pertains to social and environmental factors but is not directly related to assessing skin inflammation on the chest. While social factors can impact overall health, such as stress levels or exposure to infectious agents, the number of people living in the client's home is unlikely to be directly related to a new skin inflammation unless there are specific circumstances, such as sharing personal care products or close contact with others who have similar skin issues.

   B. Did you have a recent exposure to irritants?

   This question is highly relevant to assessing a new skin inflammation on the chest. Exposure to irritants or allergens can trigger or worsen skin conditions, such as contact dermatitis or allergic reactions. By asking about recent exposure to potential irritants like new detergents, soaps, fabrics, chemicals, or environmental factors, the nurse can gather important information to identify possible triggers for the skin inflammation.

   C. Is nausea associated with your rash?

   Nausea is typically not directly associated with a skin rash or inflammation unless there is a systemic condition or allergic reaction causing both symptoms. While it's important to assess for any systemic signs or symptoms that may be related to the skin condition, such as fever or malaise, specifically asking about nausea may not provide relevant information about the skin inflammation on the chest.

   D. What is your body mass index?

   Body mass index (BMI) is a measure of body weight relative to height and is not directly related to assessing a new skin inflammation on the chest. While obesity or changes in body weight can sometimes contribute to skin issues, such as friction-related dermatitis or hormonal changes affecting skin health, BMI alone is not a primary assessment parameter for localized skin conditions unless there are specific concerns related to weight-related skin problems.