A nurse is caring for a client who is receiving positive pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply)

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:

Urinary hesitancy, while concerning, is not typically an immediate threat to the client’s health. It can indicate underlying issues such as benign prostatic hyperplasia (BPH) or urinary tract infections, which require medical attention but are generally not life-threatening. Addressing urinary hesitancy is important, but it does not take precedence over more acute conditions.

Choice B reason:

Swollen gums can be a sign of poor oral hygiene, gingivitis, or other dental issues. While important to address, swollen gums are not usually an immediate threat to the client’s overall health. Dental issues can lead to complications if left untreated, but they do not typically require urgent intervention.

Choice C reason:

Dysphagia, or difficulty swallowing, is a priority because it can lead to serious complications such as aspiration pneumonia, malnutrition, and dehydration. Aspiration pneumonia occurs when food or liquid enters the lungs, leading to infection. Dysphagia can also cause significant discomfort and impact the client’s ability to eat and drink adequately, making it a critical issue to address promptly.

Choice D reason:

Pruritus, or itching, can be a symptom of various conditions, including allergies, skin disorders, or systemic diseases such as liver or kidney problems. While pruritus can be very uncomfortable and impact the client’s quality of life, it is not typically an immediate threat to health. It requires assessment and management but is not as urgent as dysphagia.