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

Explanation

A) Using a communication board with colored pictures might not effectively facilitate communication for someone who primarily uses sign language.
B) Requesting an interpreter during the initial assessment ensures effective communication between the nurse and the client.
C) Familiarizing themselves with commonly used signed language may help the nurse in the long term but may not be feasible or effective during the immediate admission process.

D) Asking a family member to be present during the admission may help but may not provide the necessary communication support for effective assessment and care.

A. Pain level B. Respiratory rate C. Heart rate D. Oxygenation saturation E. Blood pressure F. Echocardiogram results G. Urinary output

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

Explanation

A) The client's pain level decreased from 7 to 5 after receiving nitroglycerin. This decrease indicates improvement in the client's condition.
B) The client’s respiratory rate decreased from 24/min to 22/min.
C) The client’s heart rate decreased from 120/min to 100/min.

D) Initially, the client's oxygen saturation was 93% on room air, which decreased to 89%. However, after receiving oxygen at 2 L/min via nasal cannula it improved to 92%.
E) The blood pressure decreased from 176/82 to 110/62.

F) Only one echocardiogram result showing myocardial infarction was provided.

G) Only one reading of I&O was provided showing an output of 32 mL, hence difficult to determine whether there was an improvement.

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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.

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Explanation

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Explanation

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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.