A 35-year-old patient arrives at the Emergency Department in acute respiratory failure. What assessment information does the nurse prioritize as needing immediate action?

Choice A reason: Placing the patient on a cardiac monitor immediately is crucial due to the elevated potassium level (6.9), which can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and prompt management of any arrhythmias that may occur.

Choice B reason: Weighing the patient immediately is important for assessing fluid status and for calculating appropriate medication dosages. In patients with acute kidney injury, monitoring fluid balance is critical to prevent fluid overload and ensure accurate treatment.

Choice C reason: Anticipating a fluid bolus is not appropriate for this patient. Fluid overload can exacerbate kidney injury and worsen the patient's condition. Fluid management should be carefully tailored based on the patient's overall clinical status and needs.

Choice D reason: Asking to have the laboratory redraw the blood specimen is unnecessary if the initial results are accurate and timely. The focus should be on addressing the critical findings, such as hyperkalemia, rather than retesting.

Choice E reason: Anticipating an order for a diuretic might be considered, but it is not the immediate priority. Diuretics may be useful in managing fluid overload but do not directly address the immediate life-threatening hyperkalemia.

Choice F reason: Preparing to administer IV insulin and dextrose as ordered is essential for treating hyperkalemia. Insulin helps to shift potassium into cells, thereby lowering the serum potassium level. Dextrose is given concurrently to prevent hypoglycemia caused by insulin administration.

Choice G reason: Administering Kayexalate (sodium polystyrene) as ordered is important for removing excess potassium from the body. Kayexalate works by exchanging sodium for potassium in the intestines, promoting the excretion of potassium in the stool.

Choice A reason: Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body. The signs and symptoms include sudden shortness of breath, rapid breathing (tachypnea), rapid heart rate (tachycardia), and anxiety. These symptoms align with the patient's presentation and are common in the post-operative period, particularly after orthopedic surgery, which increases the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism.

Choice B reason: Left-sided heart failure can cause symptoms such as shortness of breath, fatigue, and fluid retention. However, the acute presentation of difficulty breathing, tachypnea, tachycardia, and anxiety in the context of recent surgery is more suggestive of a pulmonary embolism. Heart failure symptoms generally develop gradually rather than suddenly.

Choice C reason: Early onset dementia is not characterized by acute respiratory symptoms like difficulty breathing, tachypnea, or tachycardia. Dementia symptoms typically include memory loss, confusion, and changes in cognitive function, not the acute cardiorespiratory symptoms described in this scenario.

Choice D reason: Acute myocardial infarction (heart attack) can cause shortness of breath, chest pain, and rapid heart rate. While it is a possibility, the combination of recent surgery and the described symptoms more strongly suggests a pulmonary embolism. An acute myocardial infarction would typically also present with chest pain, which is not mentioned in this scenario.