A nurse is caring for a client in the emergency department.

Exhibits

The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

Hypotension

Respiratory alkalosis

Septic shock

Cardiac arrhythmias

Renal failure

Cerebral edema

Answer and Explanation

Correct Answer : A,D,E,F

A)   DKA can lead to several complications, including hypotension, which is indicated by the client's low blood pressure reading of 96/65 mm Hg.
B)   Respiratory alkalosis is less likely because DKA typically leads to metabolic acidosis, as indicated by the low pH of 7.30.
C)   DKA does not result in septic shock but it instead causes hypovolemic shock in case of severe dehydration.
D)   Cardiac arrhythmias can occur due to the electrolyte imbalances, as evidenced by the high potassium level of 5.5 mEq/L.
E)   Renal failure is another potential complication, suggested by the elevated creatinine level of 1.7 mg/dL. The client's hyperglycemia and dehydration can stress the kidneys, potentially leading to acute kidney injury or renal failure.
F)   Cerebral edema is a less common but severe complication of DKA, especially in children and adolescents, and should be considered given the client's symptoms of frequent urination and extreme thirst. It results from over-hydration of the client.

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Correct Answer is ["B","C","D"]

Explanation

A) Infusing 0.9% sodium chloride is incorrect as it's not appropriate for TPN administration.
B) Obtaining the client's weight daily helps to monitor nutritional status and adjust TPN accordingly.
C) Monitoring serum blood glucose is essential due to the high glucose content in TPN, which can lead to hyperglycemia.
D) Verifying the solution with another RN prior to infusion is a safety measure to ensure the correct solution and dosage.
E) Increasing the rate of infusion if administration is delayed may lead to complications and is not appropriate without medical orders.

A. Limit time for visitors to 2 hr per day. B. Instruct visitors to remain 6 feet from the client. C. Discard the radioactive device in the client's trash can. D. Keep soiled bed linens in the client's room. E. Keep soiled bed linens in the client's room.

Correct Answer is B

Explanation

A) Limiting time for visitors is necessary in this case. However, the time should be limited to 1 hour in 24 hours and not 2 hours.
B) Instructing visitors to remain 6 feet from the client is crucial for their safety to minimize radiation exposure. Brachytherapy involves the use of a radioactive source placed close to or inside the tumor, and while the patient is emitting radiation, safety precautions must be taken to protect others from exposure. Safety measures such as maintaining a safe distance help ensure that the radiation exposure to others is As Low As Reasonably Achievable (ALARA), a principle that aims to minimize exposure while achieving the necessary therapeutic effect.
C) Discarding the radioactive device in the client's trash can is incorrect as it poses a risk of exposure to others.
D) Keeping soiled bed linens in the client's room is incorrect as they may be contaminated with radiation and should be handled according to radiation safety protocols.

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A nurse is caring for a client in the emergency department. Exhibits The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

Nursing Test Bank

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A nurse is caring for a client in the emergency department.

Exhibits

The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.