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 B

Explanation

Choice A: Docusate. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. Docusate is a stool softener that can prevent constipation and straining, but it is not indicated for ulcerative colitis.

Choice B: A corticosteroid medication. This is a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis, which is a chronic inﬂammatory bowel disease that causes ulcers and inﬂammation in the colon and rectum. A corticosteroid medication, such as prednisone, can reduce inﬂammation, suppress the immune system, and relieve symptoms such as diarrhea, bleeding, and pain.

Choice C: Aspirin. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. Aspirin is a nonsteroidal anti-inﬂammatory drug (NSAID) that can relieve pain and inﬂammation, but it can also irritate the gastrointestinal mucosa and worsen ulcerative colitis.

Choice D: A bowel cathartic medication. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. A bowel cathartic medication, such as bisacodyl, can stimulate bowel movements and cleanse the colon, but it can also cause dehydration, electrolyte imbalance, and aggravate ulcerative colitis.

A. Sedentary lifestyle B. Triglyceride level of 100 mg/dL C. Blood glucose of 98 mg/dL D. Recent viral infection

Correct Answer is A

Explanation

Choice A: Sedentary lifestyle. This is a risk factor for developing type 2 diabetes mellitus, which is a condition that occurs when the body becomes resistant to the action of insulin or does not produce enough insulin to maintain normal blood glucose levels. Insulin is a hormone that helps glucose enter the cells and be used for energy. A sedentary lifestyle can increase the risk of type 2 diabetes mellitus by reducing physical activity, which can improve insulin sensitivity and lower blood glucose levels.

Choice B: Triglyceride level of 100 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Triglycerides are a type of fat that circulates in the blood and can be used for energy or stored in adipose tissue. A high triglyceride level can indicate an increased risk of cardiovascular disease, but it is not directly related to type 2 diabetes mellitus.

Choice C: Blood glucose of 98 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Blood glucose is the amount of glucose in the blood, which can vary depending on food intake, physical activity, and hormonal regulation. A high blood glucose level can indicate type 2 diabetes mellitus, but it is not a cause of it.

Choice D: Recent viral infection. This is not a risk factor for developing type 2 diabetes mellitus, but rather a possible trigger for type 1 diabetes mellitus, which is a condition that occurs when the immune system destroys the beta cells of the pancreas that produce insulin. A viral infection can trigger an autoimmune response that attacks the beta cells and causes type 1 diabetes mellitus.

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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?

Nursing Test Bank

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