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A nurse is admitting a 45-year-old male client who has type 1 diabetes mellitus in the emergency department.

Exhibits

Select the findings that require immediate attention.

Glasgow Coma Scale score

Client's self-monitoring of blood glucose

Bicarbonate level

Vaccess

Oxygen saturation

Blood pressure results

ECG findings

Sodium level

Answer and Explanation

Correct Answer : A,C,F,G,H

Choice A rationale:

The Glasgow Coma Scale score has decreased from 14 to 12, indicating a decline in the client's level of consciousness. This finding requires immediate attention as it may signify worsening neurological status or an underlying condition such as metabolic disturbances, hypoxia, or intracranial pathology.

Choice C rationale:

The bicarbonate level is 13 mEq/L, which is significantly lower than the normal range of 21-28 mEq/L. This indicates metabolic acidosis, a condition where the blood is too acidic. It requires immediate intervention to prevent severe complications such as shock or organ failure.

Choice F rationale:

The client's blood pressure readings show hypotension with a supine blood pressure of 100/70 mm Hg and sitting blood pressure of 85/50 mm Hg. This suggests hemodynamic instability, which could be due to dehydration, sepsis, or other critical conditions requiring urgent treatment.

Choice G rationale:

The ECG findings indicate tachycardia with a prolonged PR interval, widened QRS complex, and peaked T waves. These are signs of hyperkalemia, a potentially life-threatening condition requiring immediate attention to prevent cardiac arrest.

Choice H rationale:

The sodium level is 152 mEq/L, which is higher than the normal range of 136-145 mEq/L, indicating hypernatremia. This electrolyte imbalance can lead to severe neurological symptoms and requires prompt correction to prevent complications such as seizures or coma.

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Correct Answer is D

Explanation

Choice A rationale

Decreased serum lipase is not expected in acute pancreatitis; rather, lipase levels are typically elevated due to pancreatic enzyme leakage into the bloodstream.

Choice B rationale

Increased serum calcium is not a typical finding in acute pancreatitis; instead, hypocalcemia can occur due to fat necrosis and soap formation.

Choice C rationale

Decreased WBC is not expected; an elevated WBC count is common due to the inflammatory response associated with pancreatitis.

Choice D rationale

Increased serum amylase is a hallmark of acute pancreatitis as the damaged pancreas releases more amylase into the blood.

Correct Answer is []

Explanation

The client has respiratory acidosis as indicated by a pH of 7.25 (normal: 7.35-7.45) and elevated pCO2 of 62 mm Hg (normal: 35-45 mm Hg). This condition occurs when the lungs cannot remove enough CO2, leading to its buildup and lowering the blood pH. Immediate interventions like intubation can help manage airway and ventilation. Starting an IV drip of 0.9% sodium chloride can help address dehydration, supporting hemodynamic stability. Monitoring the correct placement of the endotracheal tube ensures effective ventilation. Regular arterial blood gases assessment helps evaluate the effectiveness of interventions and the client's respiratory status.

Prepare the client for intubation: Intubation is essential to secure the airway and provide mechanical ventilation, addressing hypoxia and hypercapnia by improving gas exchange.

Start a 0.9% sodium chloride IV drip: This fluid helps in correcting dehydration, supporting blood pressure, and improving renal perfusion, which is critical in managing acid-base balance.

Correct placement of endotracheal tube: Ensuring the tube is in the correct position guarantees effective ventilation and prevents complications such as aspiration or pneumothorax.

Arterial blood gases: Regular ABG assessments help monitor the effectiveness of ventilation and guide adjustments in therapy, ensuring the client’s acid-base balance is maintained.

Metabolic acidosis is not correct as the primary issue here is a respiratory one, indicated by elevated pCO2 and lower pH.

Respiratory alkalosis is incorrect as it would present with a high pH and low pCO2, unlike the client's findings.

Metabolic alkalosis is ruled out because it would show elevated pH and bicarbonate levels, which is not seen in the client's ABG results.

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A nurse is admitting a 45-year-old male client who has type 1 diabetes mellitus in the emergency department. Exhibits Select the findings that require immediate attention.

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Naxlex Comprehensive Predictor Exams

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down.Antacids do not help.The provider suspects acute pancreatitis.Which of the following laboratory test results should the nurse expect to see?

Correct Answer is D

Explanation

Correct Answer is []

Explanation

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A nurse is admitting a 45-year-old male client who has type 1 diabetes mellitus in the emergency department.

Exhibits

Select the findings that require immediate attention.