A nurse is assessing a client who has heart failure. Which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation?

Rationale:

A. Auscultate bowel sounds: While assessing bowel sounds can be important, it is not the priority action in this situation. The client is experiencing nausea, and the priority is to ensure their airway and safety, not just bowel function.

B. Turn the client on their side: Turning the client on their side is the priority action. This position helps prevent aspiration in case the client vomits, ensuring the airway remains clear and reducing the risk of aspiration pneumonia, especially after sedation.

C. Administer ondansetron: While ondansetron is effective for treating nausea, it is not the priority action in this case. The nurse should first ensure the client's safety by positioning them appropriately to prevent aspiration before administering medication.

D. Ensure suction equipment is available: Having suction equipment available is important for safety, but the immediate priority is positioning the client to prevent aspiration. Once the client is positioned safely, suction can be used if necessary, or be obtained if unavailable.

Rationale:

A. Renal failure: The client has elevated creatinine levels (1.7 mg/dL), which suggests kidney impairment. This could be due to dehydration and osmotic diuresis associated with hyperglycemia, which is commonly seen in diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS).

B. Hypotension: The client’s blood pressure is low (96/65 mm Hg), which can be attributed to dehydration caused by excessive urination and hyperglycemia. Hypotension can worsen as the client becomes more dehydrated, potentially progressing to shock.

C. Cerebral edema: Cerebral edema is a rare but serious complication of diabetic ketoacidosis (DKA), particularly in younger patients and those with severe electrolyte imbalances. The rapid correction of hyperglycemia can cause osmotic shifts that may lead to cerebral edema. The client’s altered fluid balance increases this risk.

D. Septic shock: Although the client has a history of bronchitis and pneumonia, there is no evidence of active sepsis at this time. Septic shock is characterized by signs of infection, such as fever and widespread infection leading to organ dysfunction. This client’s symptoms point more toward a metabolic complication rather than sepsis.

E. Respiratory alkalosis: Respiratory alkalosis occurs when there is excessive loss of carbon dioxide due to hyperventilation. In this client, there is no indication of Kussmaul respirations to suggest respiratory alkalosis. The client is more likely to develop metabolic acidosis due to the presence of ketones and a low pH (7.30).

F. Cardiac arrhythmias: Elevated potassium levels (5.5 mEq/L) and the potential for rapid fluctuations in electrolytes in a client with DKA or HHS can increase the risk of cardiac arrhythmias. Potassium imbalances hyperkalemia or hypokalemia, are closely linked to arrhythmias.