A person with a blood pH of 7.21 is considered to have which of the following?

Choice A: Peripheral pulses
Monitoring peripheral pulses is important for assessing circulation and detecting any signs of vascular complications. However, it is not the most critical assessment for a patient receiving 3% NaCl for hyponatremia. The primary concern with hypertonic saline infusion is the risk of fluid overload and central nervous system (CNS) complications.
Choice B: Urinary output
Monitoring urinary output is essential for assessing kidney function and fluid balance. While it is important, it is not the most critical assessment in this scenario. The primary risks associated with 3% NaCl infusion include rapid changes in serum sodium levels and potential CNS complications.
Choice C: Peripheral edema
Peripheral edema can indicate fluid overload, but it is not the most immediate concern when administering hypertonic saline. The nurse should prioritize monitoring for signs of pulmonary edema and neurological changes, which can occur more rapidly and have more severe consequences.
Choice D: Lung sounds and neurological status
Monitoring lung sounds and neurological status is the most important assessment for a patient receiving 3% NaCl for hyponatremia. Hypertonic saline can cause rapid shifts in fluid balance, leading to pulmonary edema and neurological complications such as osmotic demyelination syndrome. Assessing lung sounds helps detect early signs of fluid overload in the lungs, while monitoring neurological status helps identify any changes in mental status or neurological function that could indicate serious complications.

Choice A reason:

Potassium (K+) level of 5.6 mEq/L is a critical finding that requires immediate follow-up. Hyperkalemia, defined as a potassium level greater than 5.0 mEq/L, can lead to severe cardiac complications, including arrhythmias and cardiac arrest. The patient’s ECG changes, such as alterations in the T wave and PR interval, indicate that the elevated potassium level is already affecting cardiac function. Immediate intervention is necessary to lower the potassium level and prevent life-threatening complications. Normal potassium levels range from 3.5 to 5.0 mEq/L.

Choice B reason:

BP 109/70 is slightly lower than the normal range but not critically low. While it is important to monitor blood pressure, this finding does not require immediate follow-up compared to the other more critical issues. The patient’s blood pressure should be monitored regularly to ensure it does not drop further, but it is not the most urgent concern at this moment. Normal blood pressure is typically around 120/80 mmHg.

Choice C reason:

No nausea and vomiting is a positive finding indicating that the patient is not losing additional fluids and electrolytes through emesis. While it is important to note, it does not require follow-up as it does not pose an immediate risk to the patient’s health. The absence of nausea and vomiting is beneficial but does not address the primary concerns related to fluid and electrolyte imbalances.

Choice D reason:

Watery diarrhea for 3 days is a significant finding that requires follow-up due to the risk of dehydration and electrolyte imbalances. Diarrhea leads to the loss of fluids and essential electrolytes, which can result in complications such as hypovolemia and electrolyte disturbances. The patient’s ongoing diarrhea needs to be managed to prevent further fluid loss and stabilize their condition. This symptom is directly contributing to the patient’s current state of weakness and electrolyte imbalance.

Choice E reason:

Lightheaded when standing up suggests orthostatic hypotension, which can be a result of dehydration or electrolyte imbalances. This symptom indicates that the patient is experiencing hemodynamic instability, likely due to fluid loss from diarrhea. It is important to address this issue to prevent falls and further complications. Managing the underlying cause, such as rehydration and correcting electrolyte imbalances, will help stabilize the patient’s condition.

Choice F reason:

Blood Urea Nitrogen (BUN) level of 30 mg/dL is elevated, indicating impaired kidney function or dehydration. Normal BUN levels range from 6 to 24 mg/dL. An elevated BUN level 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. Addressing the elevated BUN is essential for improving renal function and overall patient health.

Choice G reason:

HR 102 is slightly elevated, indicating tachycardia. Normal heart rate ranges from 60 to 100 beats per minute. Tachycardia can be a sign of dehydration, pain, anxiety, or other underlying conditions. In this case, the elevated heart rate is likely related to the patient’s dehydration and electrolyte imbalances. Monitoring and managing the heart rate is important to ensure the patient’s cardiovascular stability. Interventions to correct fluid and electrolyte imbalances will help normalize the heart rate.

Choice H reason:

Lung sounds are clear is an important assessment finding but does not require follow-up in the context of fluid and electrolyte imbalances. Clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection. While this is a positive finding, it does not address the immediate concerns related to the patient’s fluid and electrolyte status.