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. Jerking movements of the extremities are not typical of chemotherapy-induced peripheral neuropathy. These movements could indicate other neurological disorders, such as tremors or dyskinesia.
B. Extremities turning blue when exposed to cold suggests a vascular issue, such as Raynaud's phenomenon, rather than neuropathy. Chemotherapy-induced peripheral neuropathy primarily affects sensation and not blood flow.
C. Spasms of the extremities are more indicative of muscle or electrolyte imbalances rather than neuropathy. Peripheral neuropathy typically causes sensory symptoms like tingling or numbness rather than muscle spasms.
D. Tingling or a burning sensation in the extremities, known as paresthesia, is a common symptom of chemotherapy-induced peripheral neuropathy. This condition affects the sensory nerves and can lead to these types of sensations.
Correct Answer is B
Explanation
A. Osteoarthritis is not known to cause SIADH. It is a degenerative joint disease and does not typically affect antidiuretic hormone regulation.
B. Small Cell Lung cancer is associated with SIADH as it can produce ectopic ADH, leading to increased water retention and dilutional hyponatremia.
C. Dyspepsia is a digestive disorder and is not related to SIADH. It involves discomfort or pain in the upper abdomen.
D. Liver cirrhosis can cause fluid imbalance and hyponatremia, but it is not a primary cause of SIADH. SIADH is more commonly associated with malignancies like Small Cell Lung cancer.
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