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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Dysphagia. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Dysphagia is difficulty swallowing, which can be caused by disorders of the esophagus, throat, or nervous system. It is not related to hyperparathyroidism or calcium and phosphorus levels.
Choice B: Pathologic fractures. This is a complication that the nurse should monitor the client for who has hyperparathyroidism, which is a condition that occurs when the parathyroid glands produce too much parathyroid hormone (PTH). PTH regulates calcium and phosphorus levels in the blood and bones. Hyperparathyroidism can cause hypercalcemia, which is a high level of calcium in the blood, and hypophosphatemia, which is a low level of phosphorus in the blood. These imbalances can lead to bone resorption, which is the breakdown of bone tissue and release of calcium into the blood. Bone resorption can weaken the bones and increase the risk of pathologic fractures, which are fractures that occur due to disease or injury to the bone.
Choice C: Fluid retention. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Fluid retention is excess fluid accumulation in the body, which can be caused by disorders of the heart, kidney, liver, or lymphatic system. It is not related to hyperparathyroidism or calcium and phosphorus levels.
Choice D: Impaired skin integrity. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Impaired skin integrity is damage or loss of skin tissue, which can be caused by trauma, infection, inflammation, or pressure. It is not related to hyperparathyroidism or calcium and phosphorus levels.
Correct Answer is C
Explanation
Choice A: Hypernatremia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Hypernatremia is a high level of sodium in the blood, which can be caused by dehydration, excessive sodium intake, or kidney dysfunction. It is not related to Addison’s disease or cortisol and aldosterone levels.
Choice B: Bradycardia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Bradycardia is a slow heart rate, which can be caused by vagal stimulation, medication side effects, or cardiac disorders. It is not related to Addison’s disease or cortisol and aldosterone levels.
Choice C: Hypotension. This is a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease, which is a condition that occurs when the adrenal glands do not produce enough cortisol and aldosterone. Cortisol is a hormone that regulates the metabolism of carbohydrates, proteins, and fats, and helps the body cope with stress. Aldosterone is a hormone that regulates the balance of sodium and potassium in the blood and fluid volume. Addison’s disease can cause hypotension, which is a low blood pressure, due to decreased aldosterone production and fluid loss.
Choice D: Hypokalemia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Hypokalemia is a low level of potassium in the blood, which can be caused by diuretics, vomiting, diarrhea, or alkalosis. It is not related to Addison’s disease or cortisol and aldosterone levels.
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