The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?

Client's serum pH is 7.41

Client has a stage 2 sacral wound

Client requires continuous nasogastric suction

Client has a history of adrenal insufficiency

Answer and Explanation

The Correct Answer is C

A. Client's serum pH is 7.41: This is within the normal range for blood pH (7.35-7.45) and does not specifically indicate a potassium deficit.
B. Client has a stage 2 sacral wound: This is related to skin integrity and does not directly impact potassium levels.
C. Client requires continuous nasogastric suction: Continuous nasogastric suction can lead to the loss of potassium as it removes gastric contents, which may include electrolytes.
D. Client has a history of adrenal insufficiency: While adrenal insufficiency can affect electrolyte balance, continuous nasogastric suction is a more immediate risk for potassium deficit.

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Correct Answer is C

Explanation

A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.

A. Respiratory acidosis without compensation B. Metabolic acidosis with full compensation C. Respiratory acidosis with partial compensation D. Metabolic acidosis without compensation

Correct Answer is C

Explanation

A. Respiratory acidosis without compensation: The pH of 7.22 indicates acidosis, but the HCO3 level of 23 mEq/L suggests that compensation is occurring because the HCO3 is within the normal range for respiratory acidosis.
B. Metabolic acidosis with full compensation: The high PaCO2 level is more indicative of respiratory issues, not metabolic acidosis. Additionally, compensation for metabolic acidosis would show elevated HCO3.
C. Respiratory acidosis with partial compensation: The elevated PaCO2 and low pH indicate respiratory acidosis. The normal HCO3 level suggests partial compensation by the kidneys.
D. Metabolic acidosis without compensation: The elevated PaCO2 and normal HCO3 suggest respiratory acidosis rather than metabolic acidosis.

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The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

An unresponsive client was brought to the emergency room and had an arterial blood gas drawn. Ten minutes later, the laboratory calls with the following results: PaO2 74%, pH 7.22, PaCO2 85 mm Hg, and HCO3 23 mEq/L. The nurse interprets the results as indicating which imbalance?

Correct Answer is C

Explanation

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