A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance?

Choice A reason:

Watery diarrhea for 3 days is a significant finding that correlates with fluid and electrolyte imbalances. Diarrhea leads to the loss of fluids and electrolytes, which can result in dehydration and electrolyte disturbances such as hypokalemia or hyperkalemia. In this case, the patient’s potassium level is elevated (5.6 mEq/L), which could be a result of the body’s attempt to compensate for the loss of other electrolytes. Diarrhea also contributes to the patient’s weakness and lightheadedness due to dehydration.

Choice B reason:

Chronic kidney disease, which has been managed with diuretics and fluid restrictions, is another critical factor. Chronic kidney disease (CKD) affects the body’s ability to regulate fluid and electrolytes. The use of diuretics can exacerbate electrolyte imbalances, particularly potassium levels. In this scenario, the patient’s elevated potassium level (5.6 mEq/L) is concerning, as CKD patients are at higher risk for hyperkalemia due to decreased renal excretion of potassium. The combination of CKD and recent diarrhea increases the complexity of managing the patient’s fluid and electrolyte balance.

Choice C reason:

Lung sounds are clear is an important assessment finding but does not directly correlate with the primary nursing problem of fluid and electrolyte imbalance. While clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection, this finding does not address the immediate concerns related to fluid loss and electrolyte disturbances. Therefore, it is not a priority in this context.

Choice D reason:

No nausea and vomiting is a relevant finding but does not directly correlate with the primary nursing problem. The absence of nausea and vomiting is positive, as it indicates that the patient is not losing additional fluids and electrolytes through emesis. However, it does not address the significant fluid loss from diarrhea or the electrolyte imbalances that are the primary concerns in this scenario.

Choice E reason:

History of hypertension is a relevant factor in the patient’s overall health status. Hypertension can complicate the management of fluid and electrolyte imbalances, particularly in patients with CKD. The use of antihypertensive medications and diuretics can affect electrolyte levels and fluid balance. In this case, the patient’s blood pressure is slightly low (109/70), which could be related to dehydration from diarrhea and the effects of antihypertensive medications. This history is important for understanding the patient’s baseline and potential complications.

Choice F reason:

Blood urea nitrogen (BUN) is elevated at 30 mg/dL, which is above the normal range (6-24 mg/dL). An elevated BUN level indicates impaired kidney function and can be a sign of dehydration or renal insufficiency. In the context of CKD and recent diarrhea, an elevated BUN suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions.

Choice A: Show the caregiver how to check the patient’s temperature and blood pressure
Showing the caregiver how to check the patient’s temperature and blood pressure involves direct patient education and demonstration, which requires the clinical judgment and expertise of a licensed nurse. This task ensures that the caregiver understands the correct techniques and can accurately monitor the patient’s vital signs. Delegating this task to assistive personnel (AP) is not appropriate because it requires a higher level of skill and knowledge to teach and verify understanding.
Choice B: Give the patient a pamphlet that reinforces teaching done by the nurse
Giving the patient a pamphlet that reinforces teaching done by the nurse is a task that can be delegated to assistive personnel (AP). This action does not require clinical judgment or advanced skills. The pamphlet serves as a supplementary resource to the verbal and hands-on education provided by the nurse. It is a straightforward task that AP can perform, ensuring that the patient has access to written information that reinforces the nurse’s teaching.
Choice C: Evaluate whether the patient and caregiver understand the teaching
Evaluating whether the patient and caregiver understand the teaching is a critical component of the discharge process that requires the clinical judgment of a licensed nurse. This task involves assessing the patient’s and caregiver’s comprehension, identifying any gaps in understanding, and providing additional education as needed. It is not appropriate to delegate this responsibility to assistive personnel (AP) because it requires professional assessment skills.
Choice D: Plan topics for the discharge teaching session with the patient and caregiver
Planning topics for the discharge teaching session with the patient and caregiver involves developing a comprehensive and individualized teaching plan based on the patient’s specific needs and condition. This task requires the expertise and clinical judgment of a licensed nurse to ensure that all relevant topics are covered and that the teaching plan is tailored to the patient’s situation. Delegating this task to assistive personnel (AP) is not appropriate because it requires advanced planning and professional knowledge.