A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

Choice A reason:

Watery diarrhea for 3 days is a significant finding that correlates with fluid and electrolyte imbalances. Diarrhea leads to the loss of fluids and electrolytes, which can result in dehydration and electrolyte disturbances such as hypokalemia or hyperkalemia. In this case, the patient’s potassium level is elevated (5.6 mEq/L), which could be a result of the body’s attempt to compensate for the loss of other electrolytes. Diarrhea also contributes to the patient’s weakness and lightheadedness due to dehydration.

Choice B reason:

Chronic kidney disease, which has been managed with diuretics and fluid restrictions, is another critical factor. Chronic kidney disease (CKD) affects the body’s ability to regulate fluid and electrolytes. The use of diuretics can exacerbate electrolyte imbalances, particularly potassium levels. In this scenario, the patient’s elevated potassium level (5.6 mEq/L) is concerning, as CKD patients are at higher risk for hyperkalemia due to decreased renal excretion of potassium. The combination of CKD and recent diarrhea increases the complexity of managing the patient’s fluid and electrolyte balance.

Choice C reason:

Lung sounds are clear is an important assessment finding but does not directly correlate with the primary nursing problem of fluid and electrolyte imbalance. While clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection, this finding does not address the immediate concerns related to fluid loss and electrolyte disturbances. Therefore, it is not a priority in this context.

Choice D reason:

No nausea and vomiting is a relevant finding but does not directly correlate with the primary nursing problem. The absence of nausea and vomiting is positive, as it indicates that the patient is not losing additional fluids and electrolytes through emesis. However, it does not address the significant fluid loss from diarrhea or the electrolyte imbalances that are the primary concerns in this scenario.

Choice E reason:

History of hypertension is a relevant factor in the patient’s overall health status. Hypertension can complicate the management of fluid and electrolyte imbalances, particularly in patients with CKD. The use of antihypertensive medications and diuretics can affect electrolyte levels and fluid balance. In this case, the patient’s blood pressure is slightly low (109/70), which could be related to dehydration from diarrhea and the effects of antihypertensive medications. This history is important for understanding the patient’s baseline and potential complications.

Choice F reason:

Blood urea nitrogen (BUN) is elevated at 30 mg/dL, which is above the normal range (6-24 mg/dL). An elevated BUN level indicates impaired kidney function and can be a sign of dehydration or renal insufficiency. In the context of CKD and recent diarrhea, an elevated BUN suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions.

Choice A: Alkalosis
Alkalosis occurs when the blood pH is higher than the normal range, specifically above 7.45. This condition indicates that the blood is too alkaline. Causes of alkalosis can include hyperventilation, loss of stomach acid through vomiting, or an overuse of diuretics. Since a blood pH of 7.21 is below the normal range, it does not indicate alkalosis.
Choice B: Normal Blood pH
The normal pH range for blood is between 7.35 and 7.45. This range is crucial for the body’s metabolic processes and enzyme functions. A blood pH of 7.21 is below this range, indicating an abnormal condition.
Choice C: Acidosis
Acidosis is the correct answer. It occurs when the blood pH drops below 7.35, indicating that the blood is too acidic. A pH of 7.21 is significantly below the normal range, confirming acidosis. This condition can result from various factors, including respiratory issues that lead to an accumulation of carbon dioxide or metabolic problems that increase acid production or decrease bicarbonate levels.
Choice D: Hyperkalemia
Hyperkalemia refers to an elevated level of potassium in the blood, not a change in blood pH. While hyperkalemia can be associated with acidosis, it is not defined by the pH level itself. Therefore, a blood pH of 7.21 does not directly indicate hyperkalemia.