Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?

Reference Range:

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
.

Surgical consent form is not signed.

Client's pulse oximeter reading is 96%.

Preoperative chest x-ray report is not available.

Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L).

Answer and Explanation

The Correct Answer is D

A.   The surgical consent form is crucial for ensuring that the client is informed about the procedure and agrees to it. While it's critical for legal and ethical reasons, this issue can often be resolved relatively quickly by having the client sign the form or addressing it with the surgeon.
B.   A pulse oximeter reading of 96% indicates that the client's oxygen saturation is within a generally acceptable range (normal is usually 95% to 100%). This reading suggests that the client's oxygen levels are adequate and typically would not require immediate action.
C.   The absence of a preoperative chest x-ray report can be significant, especially if the client has underlying respiratory or cardiac conditions. However, the immediate need for action depends on the urgency and the reason the x-ray was ordered.
D.   A serum potassium level of 2.8 mEq/L is critically low. The normal reference range is 3.5 to 5 mEq/L. Hypokalemia (low potassium) can lead to severe complications, including cardiac arrhythmias and muscle weakness, which can significantly impact the client's ability to safely undergo surgery. This condition requires immediate attention to correct the electrolyte imbalance before proceeding with the surgical procedure.

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Correct Answer is B

Explanation

A. Client describes a schedule for antacid use with other prescribed medications: While antacids might be part of the management plan, they do not address the underlying issue of rapid gastric emptying.
B. This is the most relevant outcome for a client who has developed post-Billroth II dumping syndrome, characterized by nausea, diarrhea, and diaphoresis after meals. Small, frequent meals with fluid intake between meals can help regulate blood sugar levels and reduce the rapid emptying of stomach contents into the small intestine, which is a primary cause of dumping syndrome.
C. Smoking can affect overall health but is not directly related to dumping syndrome.
D. Stress management is important for overall well-being but does not directly address the physiological changes causing dumping syndrome.

A. Weight gain. B. Hypoventilation. C. Cold intolerance. D. Lethargy

Correct Answer is B

Explanation

A. Weight gain is a common symptom of hypothyroidism but it is not an immediate threat to life. It can be managed with diet and medication.
B. Hypoventilation, or decreased respiratory rate, can lead to hypoxemia (low oxygen levels in the blood) and hypercapnia (increased carbon dioxide levels in the blood). These conditions can rapidly deteriorate into a respiratory crisis and require immediate intervention.
C. Cold intolerance is a common symptom of hypothyroidism but is not an immediate threat to life. It can be managed with warm clothing and a warm environment.
D. Lethargy is another common symptom of hypothyroidism but is not an immediate threat to life. It can be managed with medication and lifestyle changes.
8. The nurse reviews discharge instructions with a client

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Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] .

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The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?

Reference Range:

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
.