Instructions:
Use this scenario for the next 4 questions.
Indicate which assessment findings correlate with the nursing problem you identified. (Select all that apply)
Watery diarrhea for 3 days.
Chronic kidney disease, which has been managed with diuretics and fluid restrictions.
Lung sounds are clear.
No nausea and vomiting.
History of hypertension.
Blood urea nitrogen (BUN).
Correct Answer : A,B,E,F
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F","G"]
Explanation
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.
Correct Answer is A
Explanation
Choice A: Infuse the KCl at a maximum rate of 10 mEq/hr
This is the correct answer. The recommended infusion rate for potassium chloride is generally not to exceed 10 mEq per hour to avoid complications such as hyperkalemia and cardiac arrhythmias. This rate ensures that the potassium is administered safely and effectively, allowing for proper monitoring and adjustment if necessary.
Choice B: Discontinue cardiac monitoring during the infusion
This choice is incorrect. Cardiac monitoring is essential during the infusion of potassium chloride, especially in patients with severe hypokalemia, due to the risk of arrhythmias and other cardiac complications. Continuous monitoring allows for the early detection of any adverse effects and timely intervention.
Choice C: Administer the KCl as a rapid IV bolus
Administering potassium chloride as a rapid IV bolus is dangerous and contraindicated. Rapid infusion can lead to severe hyperkalemia, which can cause fatal cardiac arrhythmias. Potassium chloride should always be administered slowly and diluted in an appropriate volume of fluid.
Choice D: Refuse to give the KCl through a peripheral venous line
While central lines are preferred for higher concentrations of potassium chloride due to the risk of irritation and phlebitis, peripheral lines can be used for lower concentrations and slower infusion rates. Refusing to administer potassium chloride through a peripheral line is not necessary if the infusion is properly managed and monitored.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today