A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain.
Exhibits
Select the top 4 client findings that requires immediate follow up.
Potassium 7.0 mEq/L (3.5 to 5 mEq/L)
WBC count 17,000/mm3 (Normal Finding: 5,000 to 10,000/mm3)
Crackles throughout lungs
Creatinine 3.0 mg/dL (0.5 to 1.3 mg/dL)
Abdomen rigid with decreased bowel sounds
Glucose 250 mg/dL
No dialysis for 24 hr
Hemoglobin 10 g/dL (12 to 18 g/dL) Nausea
Correct Answer : A,B,C,H
A. Potassium 7.0 mEq/L (3.5 to 5 mEq/L): Elevated potassium levels (hyperkalemia) can cause life-threatening cardiac arrhythmias and are especially concerning in clients with chronic kidney disease who are at risk of renal complications. Immediate follow-up is crucial to prevent severe cardiac effects.
B. WBC count 17,000/mm³ (Normal Finding: 5,000 to 10,000/mm³): An elevated WBC count indicates an infection or inflammation, which is concerning given the client’s symptoms and temperature. This finding requires immediate follow-up to address potential infection.
C. Crackles throughout lungs: Crackles may indicate fluid overload or pulmonary edema, particularly in clients with chronic kidney disease. This could be a sign of worsening renal function or heart failure, which requires prompt attention.
H. No dialysis for 24 hr: Missing dialysis sessions in a client with stage IV chronic kidney disease can lead to dangerous fluid and electrolyte imbalances. This finding requires immediate action to prevent complications related to renal failure.
Explanation of Incorrect Options:
E. Creatinine 3.0 mg/dL (0.5 to 1.3 mg/dL): While elevated creatinine levels are concerning, the client’s history of chronic kidney disease means this level is expected to be higher. However, it is not as immediately critical as the other findings.
F. Abdomen rigid with decreased bowel sounds: This may suggest abdominal complications but is not as immediately critical as issues related to hyperkalemia or infection.
G. Glucose 250 mg/dL: Elevated glucose levels are concerning but less immediately critical compared to severe electrolyte imbalances and potential infections.
H. Hemoglobin 10 g/dL (12 to 18 g/dL): Anemia is a concern but is not as urgent as the immediate risks posed by elevated potassium, signs of infection, or missed dialysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Suctioning the nostril is not appropriate as it could exacerbate potential cerebrospinal fluid (CSF) leakage or cause further injury.
B. Asking the client to blow their nose could increase intracranial pressure and potentially worsen a skull fracture or CSF leak.
C. While notifying the physician is important, the initial step should be to determine whether the clear drainage is CSF, which has specific implications.
D. Testing the drainage for glucose is crucial because a positive glucose test indicates that the fluid is likely CSF, which can signal a skull fracture and possible brain injury. This finding requires immediate medical evaluation to manage potential complications like infections or worsening of the fracture.
Correct Answer is D
Explanation
A. Holding the client's arms and legs can cause injury and does not help in managing the seizure. The focus should be on protecting the client from harm.
B. Moving the client back to bed during a seizure can be dangerous and increase the risk of injury. It's best to manage the seizure where the client is.
C. Inserting a tongue blade or any object into the client's mouth can cause injury to the teeth or oral cavity and is not recommended during a seizure.
D. Placing the client on his side helps maintain an open airway and prevents aspiration, which is crucial during a seizure to ensure the client’s safety.
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