The nurse received the morning shift report on four clients.
Which client should the nurse assess first?
A client 1 day post-op with a temperature of 38.2°C (100.9°F).
A client with pancreatitis reporting abdominal pain 8/10 and nausea.
A client with cirrhosis who is increasingly confused and has asterixis.
A client with a potassium level of 6.8 mEq/L who has peaked T waves on ECG.
The Correct Answer is D
Nursing prioritization relies on the ABC framework and identifying the most immediate threat to life. Knowledge of electrolyte imbalances and cardiac conduction must be applied here to recognize that severe hyperkalemia poses an imminent risk of lethal cardiac arrhythmias.
Choice A rationale
A low grade fever of 38.2 C on the first postoperative day is common due to the inflammatory response or atelectasis. While it requires monitoring and lung expansion exercises, it is not an immediate life threat.
Choice B rationale
Severe abdominal pain and nausea are classic symptoms of acute pancreatitis. While the patient is in significant distress and needs analgesia, this presentation is expected for the diagnosis and is second to cardiovascular instability.
Choice C rationale
Confusion and asterixis in cirrhosis indicate hepatic encephalopathy due to elevated ammonia. Normal ammonia is 15 to 45 mcg/dL. This requires treatment with lactulose but is less immediately fatal than a cardiac arrest.
Choice D rationale
A potassium level of 6.8 mEq/L is critically high, as the normal range is 3.5 to 5.0 mEq/L. Peaked T waves indicate myocardial irritability, which can progress rapidly to ventricular fibrillation or asystole, requiring emergent intervention..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
These situations require an understanding of how surgical trauma affects endocrine and integumentary systems. Recognizing early signs of hypocalcemia and understanding the pathophysiology of eschar-induced constriction is essential for preventing permanent tissue damage, cardiovascular collapse, or neurological dysfunction in acute care.
Choice A rationale
Kernig sign involves resistance to knee extension when the hip is flexed, indicating meningeal irritation. It is not related to calcium levels or thyroid surgery, where normal serum calcium ranges from 8.5 to 10.5 mg/dL.
Choice B rationale
Chvostek sign is a twitching of the facial muscles when the facial nerve is tapped. This indicates hypocalcemia, a common complication of subtotal thyroidectomy due to accidental parathyroid injury, resulting in neuromuscular irritability and tingling sensations.
Choice C rationale
The Babinski sign is an abnormal upward movement of the great toe in adults, indicating upper motor neuron lesions. It does not assess for mineral imbalances like low calcium, which typically presents with paresthesia and positive tetany signs.
Choice D rationale
Brudzinski sign is characterized by involuntary hip and knee flexion when the neck is flexed, signifying meningitis. While it indicates neurological irritation, it is not a diagnostic tool for postoperative hypocalcemia following a thyroidectomy procedure.
Correct Answer is A
Explanation
Pancreatitis often leads to electrolyte imbalances, specifically hypocalcemia due to fat necrosis and soap formation. Knowledge of cardiac electrophysiology is required to recognize how low calcium levels (normal 8.5 to 10.5 mg/dL) affect the myocardial action potential.
Choice A rationale
Prolonged QT interval is a classic electrocardiogram finding in hypocalcemia. Low serum calcium slows the movement of calcium into the cardiac cells during the plateau phase, thereby lengthening the duration of ventricular depolarization and repolarization cycles.
Choice B rationale
A shortened PR interval is not associated with hypocalcemia. PR interval changes are more frequently linked to pre-excitation syndromes or inflammatory conditions of the heart, rather than the specific electrolyte shifts seen in acute pancreatic inflammation.
Choice C rationale
Peaked T waves are a hallmark sign of hyperkalemia, not hypocalcemia. In hypocalcemia, the T wave may actually appear flattened or inverted, but the most distinctive and supportive finding remains the elongation of the QT interval.
Choice D rationale
Elevated ST segments are typically indicative of myocardial infarction or pericarditis. While electrolyte imbalances can cause various cardiac changes, ST elevation is not the primary diagnostic indicator used to support a suspicion of clinical hypocalcemia.
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