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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

High-protein and high-carbohydrate foods are beneficial, but they do not directly address the immediate respiratory issues in ARDS.

Choice B rationale

Encouraging oral intake of fluids may not be appropriate as it can contribute to fluid overload and worsen pulmonary edema in ARDS patients.

Choice C rationale

Administering low-flow oxygen might be necessary but isn't the most crucial intervention for ARDS. High-flow oxygen or mechanical ventilation is typically required.

Choice D rationale

Placing the client in a prone position has been shown to improve oxygenation in ARDS by enhancing lung expansion and ventilation-perfusion matching.

A. Milky fluid. B. Bloody fluid. C. Viscous fluid. D. Purulent fluid.

Correct Answer is D

Explanation

Choice A rationale

Milky fluid often indicates chylothorax, a condition where lymphatic fluid leaks into the pleural space, and is not necessarily indicative of infection.

Choice B rationale

Bloody fluid may indicate trauma or malignancy but not necessarily infection.

Choice C rationale

Viscous fluid can be related to various conditions, including malignant effusion, but does not specifically indicate infection.

Choice D rationale

Purulent fluid is indicative of an infection as it contains pus, which is a collection of dead white blood cells, bacteria, and tissue debris.

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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.

Nursing Test Bank

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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.