A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following actions should the nurse take?

The correct answer is: The nurse has reviewed the client’s medical record. The client is at risk for developing

Hypotension and Metabolic Acidosis

Choice A: Hyperkalemia

Hyperkalemia refers to an elevated level of potassium in the blood. The normal range for potassium is 3.5 to 5.0 mEq/L. In this case, the client’s potassium level is 5.0 mEq/L, which is at the upper limit of normal. While the client is not currently hyperkalemic, they are at risk due to their condition. However, hyperkalemia is not the most immediate concern based on the provided data. The client’s symptoms and diagnostic results point more directly to other conditions.

Choice B: Hypertension

Hypertension is high blood pressure. The client’s blood pressure is 96/68 mm Hg, which is below the normal range (typically around 120/80 mm Hg). This indicates hypotension rather than hypertension. Given the client’s history of hypertension, the current low blood pressure is concerning and suggests a different issue, such as dehydration or fluid loss from diarrhea.

Choice C: Hypokalemia

Hypokalemia is a condition where potassium levels are below normal. The client’s potassium level is 5.0 mEq/L, which is within the normal range. Therefore, hypokalemia is not a concern in this scenario. The client’s potassium level does not indicate a risk for hypokalemia, and their symptoms do not align with this condition.

Choice D: Hypernatremia

Hypernatremia is an elevated sodium level in the blood. The normal range for sodium is 136 to 145 mEq/L. The client’s sodium level is 149 mEq/L, which is above the normal range, indicating hypernatremia. This condition can result from dehydration, which is consistent with the client’s symptoms of diarrhea and poor skin turgor. However, while hypernatremia is a concern, it is not the most critical issue compared to hypotension and metabolic acidosis.

Choice E: Hypotension

Hypotension is low blood pressure. The client’s blood pressure is 96/68 mm Hg, which is below the normal range. This low blood pressure, combined with symptoms of weakness, dizziness, and poor skin turgor, suggests significant fluid loss and dehydration. Hypotension is a critical concern as it can lead to inadequate perfusion of organs and tissues, potentially causing further complications.

Choice F: Renal Failure

Renal failure refers to the kidneys’ inability to filter waste from the blood effectively. While the client’s urine output is low (30 mL/hr), which could indicate renal impairment, there is no direct evidence from the provided data to confirm renal failure. The client’s basic metabolic profile does not show elevated creatinine or BUN levels, which are typical indicators of renal function.

Choice G: Metabolic Acidosis

Metabolic acidosis is a condition where there is too much acid in the body fluids. The normal range for blood pH is 7.35 to 7.45. The client’s pH is 7.33, which is below the normal range, indicating acidosis. Additionally, the bicarbonate (HCO3) level is 19 mEq/L, which is below the normal range of 21 to 28 mEq/L. These findings confirm metabolic acidosis, likely due to the loss of bicarbonate through diarrhea.

Choice A reason: Drive the client to the nearest emergency department

While it might seem helpful to drive the client to the nearest emergency department, it is not the best course of action. The symptoms described—right-sided weakness and slurred speech—are indicative of a possible stroke. Time is critical in stroke management, and emergency services can provide immediate medical intervention and transport to a stroke center, which is essential for the best possible outcome.

Choice B reason: Call emergency services

Calling emergency services is the most appropriate action. The client is exhibiting signs of a stroke, and rapid medical intervention is crucial. Emergency medical services (EMS) can begin treatment en route to the hospital and ensure the client is taken to a facility equipped to handle strokes. This action maximizes the chances of a positive outcome by minimizing delays in treatment.

Choice C reason: Find a location for the client to sit

Finding a location for the client to sit might provide temporary comfort, but it does not address the urgent need for medical intervention. In the case of a suspected stroke, immediate action is necessary to prevent further damage. Sitting the client down does not provide the critical care needed in this situation.

Choice D reason: Obtain the telephone number of the client’s provider

Obtaining the telephone number of the client’s provider is not the priority in an emergency situation like this. While it might be useful information later, the immediate need is to get the client to a hospital as quickly as possible. Contacting the provider can be done after emergency services have been called.