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

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.

Respiratory alkalosis

Hypotension

Septic shock

Cardiac arrhythmias

Renal failure

Cerebral edema

Answer and Explanation

Correct Answer : B,D,E,F

A. Respiratory alkalosis: The client’s arterial pH is 7.30, indicating acidemia rather than alkalemia. Respiratory alkalosis is not expected in hyperglycemic crises; instead, metabolic acidosis may develop due to ketone accumulation and dehydration.

B. Hypotension: The client’s blood pressure is 96/65 mm Hg, which is lower than normal, likely related to dehydration from osmotic diuresis caused by severe hyperglycemia. Ongoing fluid loss increases the risk of hypotension, making it an important complication to monitor and manage promptly.

C. Septic shock: While the client has a recent history of bronchitis and pneumonia, there is no current evidence of infection such as fever, tachypnea, or elevated WBCs. Although infection could precipitate hyperglycemia, septic shock is not an immediate complication indicated by the current findings.

D. Cardiac arrhythmias: The client has a potassium level of 5.5 mEq/L, which is elevated. Hyperkalemia increases the risk of cardiac arrhythmias, especially in combination with dehydration and acidosis, making close cardiac monitoring necessary.

E. Renal failure: Elevated BUN (21 mg/dL) and creatinine (1.7 mg/dL) suggest impaired renal perfusion or acute kidney injury secondary to dehydration from osmotic diuresis. The client is at risk of progression to renal failure if fluid and electrolyte imbalances are not corrected.

F. Cerebral edema: Cerebral edema is often caused by an overly rapid drop in effective serum osmolarity during treatment, primarily when blood glucose is lowered too quickly. The rapid shift in fluid from the bloodstream to the brain cells can cause swelling.

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Correct Answer is A

Explanation

Rationale:

A. Yankauer catheter: A Yankauer catheter is a rigid suction device designed for clearing oral secretions, primarily in the mouth and pharynx. It is not suitable for tracheostomy suctioning because it cannot safely reach into the trachea and may cause trauma if used intratracheally. Tracheostomy suctioning requires a flexible, sterile suction catheter.

B. Sterile water: Sterile water or sterile saline is used to flush the suction catheter before and after tracheostomy suctioning. It helps maintain catheter patency and clears secretions, reducing the risk of obstruction during the procedure. Using sterile solutions also prevents introducing pathogens into the airway, which is critical for infection prevention.

C. Nasal cannula: A nasal cannula delivers supplemental oxygen but is not used for the suctioning procedure itself. While oxygen may be administered before or after suctioning to prevent hypoxia, it is not considered essential equipment for performing the suctioning procedure.

D. Pulse oximeter: A pulse oximeter is used to monitor oxygen saturation and assess the client’s response to suctioning. Although important for patient safety, it is not a piece of equipment required to perform the suctioning procedure; rather, it serves as a monitoring device to guide intervention.

Correct Answer is ["125"]

Explanation

Total Volume: 500 mL

Infusion Time: 4 hours (240 minutes)

Drop Factor: 60 gtt/mL

Calculate the infusion rate in gtt/min

Infusion Rate (gtt/min) = (Total Volume × Drop Factor) ÷ Time (min)

Infusion Rate = (500 × 60) ÷ 240

Infusion Rate = 30,000 ÷ 240

Infusion Rate = 125 gtt/min

Round to the nearest whole number

= 125 gtt/min

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

Naxlex Comprehensive Predictor Exams

A nurse is assessing equipment needs in order to perform tracheostomy suctioning on a client. Which of the following pieces of equipment should the nurse gather for the procedure?

Correct Answer is A

Explanation

Correct Answer is ["125"]

Explanation

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