A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?

Potassium 2.5 mEq/L

Blood glucose 150 mg/dL

Urine specific gravity 1.035

Weight loss of 3% of total body weight.

Answer and Explanation

The Correct Answer is A

Choice A: Potassium 2.5 mEq/L. This is the priority data collection finding that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should identify potassium 2.5 mEq/L as the priority because it indicates hypokalemia, which is a low level of potassium in the blood. Potassium is an electrolyte that regulates the electrical activity of the heart and muscles. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis, which can be life-threatening.

Choice B: Blood glucose 150 mg/dL. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Blood glucose 150 mg/dL indicates hyperglycemia, which is a high level of glucose in the blood. Hyperglycemia can be caused by dehydration, stress, infection, or medication side eﬀects.

Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, and fatigue. It can also lead to complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, which are serious but not as urgent as hypokalemia.

Choice C: Urine specific gravity 1.035. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Urine specific gravity 1.035 indicates concentrated urine, which can be caused by dehydration or ﬂuid loss. Dehydration can result from vomiting and diarrhea, which are common symptoms of acute gastroenteritis. Dehydration can cause symptoms such as dry mucous membranes, tachycardia, hypotension, and oliguria. It can also lead to complications such as shock or kidney failure, which are serious but not as urgent as hypokalemia.

Choice D: Weight loss of 3% of total body weight. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Weight loss of 3% of total body weight indicates mild to moderate dehydration, which can be caused by ﬂuid loss from vomiting and diarrhea. Weight loss can also reﬂect loss of muscle mass or fat tissue due to malnutrition or inﬂammation. Weight loss can aﬀect the client’s nutritional status and immune function, but it is not as urgent as hypokalemia.

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Correct Answer is C

Explanation

Choice A: Obtain the client’s vital signs. This is an important nursing action, but not the priority. The nurse should monitor the client’s vital signs for signs of infection, ﬂuid imbalance, or shock, but these are not as urgent as relieving the client’s pain.

Choice B: Weigh the client. This is a necessary nursing action, but not the priority. The nurse should weigh the client daily to assess their ﬂuid status and nutritional needs, but this can be done after addressing the client’s pain.

Choice C: Administer pain medication. This is the priority nursing action because the nurse should follow the principle of Maslow’s hierarchy of needs and address the client’s physiological needs first. Pain can interfere with the client’s healing process and aﬀect their quality of life.

Choice D: Change the client’s dressing. This is a required nursing action, but not the priority. The nurse should change the client’s dressing to prevent infection and promote wound healing, but this can be done after administering pain medication to make the procedure more comfortable for the client.

A. Drinking orange juice regularly B. Eating dinner early in the evening C. Consuming low-fat meats D. Sleeping on a large wedge-style pillow

Correct Answer is A

Explanation

Choice A: Drinking orange juice regularly. This is a contributing factor to the client’s heartburn because orange juice is acidic and can irritate the esophageal mucosa and lower esophageal sphincter, causing reﬂux of gastric contents into the esophagus.

Choice B: Eating dinner early in the evening. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should avoid eating within 3 hours of bedtime to allow for gastric emptying and reduce the risk of reﬂux.

Choice C: Consuming low-fat meats. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should avoid high-fat foods, which can delay gastric emptying and increase intra-abdominal pressure, leading to reﬂux.

Choice D: Sleeping on a large wedge-style pillow. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should elevate the head of their bed or use a wedge pillow to create an incline that prevents gastric contents from ﬂowing back into the esophagus.

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A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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