A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?
Potassium 2.5 mEq/L
Blood glucose 150 mg/dL
Urine specific gravity 1.035
Weight loss of 3% of total body weight.
The Correct Answer is A
Choice A: Potassium 2.5 mEq/L. This is the priority data collection finding that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should identify potassium 2.5 mEq/L as the priority because it indicates hypokalemia, which is a low level of potassium in the blood. Potassium is an electrolyte that regulates the electrical activity of the heart and muscles. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis, which can be life-threatening.
Choice B: Blood glucose 150 mg/dL. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Blood glucose 150 mg/dL indicates hyperglycemia, which is a high level of glucose in the blood. Hyperglycemia can be caused by dehydration, stress, infection, or medication side effects.
Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, and fatigue. It can also lead to complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, which are serious but not as urgent as hypokalemia.
Choice C: Urine specific gravity 1.035. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Urine specific gravity 1.035 indicates concentrated urine, which can be caused by dehydration or fluid loss. Dehydration can result from vomiting and diarrhea, which are common symptoms of acute gastroenteritis. Dehydration can cause symptoms such as dry mucous membranes, tachycardia, hypotension, and oliguria. It can also lead to complications such as shock or kidney failure, which are serious but not as urgent as hypokalemia.
Choice D: Weight loss of 3% of total body weight. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Weight loss of 3% of total body weight indicates mild to moderate dehydration, which can be caused by fluid loss from vomiting and diarrhea. Weight loss can also reflect loss of muscle mass or fat tissue due to malnutrition or inflammation. Weight loss can affect the client’s nutritional status and immune function, but it is not as urgent as hypokalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Drinking orange juice regularly. This is a contributing factor to the client’s heartburn because orange juice is acidic and can irritate the esophageal mucosa and lower esophageal sphincter, causing reflux of gastric contents into the esophagus.
Choice B: Eating dinner early in the evening. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should avoid eating within 3 hours of bedtime to allow for gastric emptying and reduce the risk of reflux.
Choice C: Consuming low-fat meats. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should avoid high-fat foods, which can delay gastric emptying and increase intra-abdominal pressure, leading to reflux.
Choice D: Sleeping on a large wedge-style pillow. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should elevate the head of their bed or use a wedge pillow to create an incline that prevents gastric contents from flowing back into the esophagus.
Correct Answer is D
Explanation
Choice A: Bradycardia. This is not a manifestation of gastrointestinal perforation, but rather a sign of vagal stimulation, which can occur in response to gastric distension, vomiting, or suctioning. Vagal stimulation can slow down the heart rate and lower the blood pressure.
Choice B: Hyperactive bowel sounds. This is not a manifestation of gastrointestinal perforation, but rather a sign of increased intestinal motility, which can occur in response to inflammation, infection, or irritation of the gastrointestinal tract. Hyperactive bowel sounds are loud, high-pitched, and frequent.
Choice C: Report of epigastric fullness. This is not a manifestation of gastrointestinal perforation, but rather a sign of delayed gastric emptying, which can occur in response to gastric outlet obstruction, gastroparesis, or pyloric stenosis. Epigastric fullness is a feeling of pressure or discomfort in the upper abdomen after eating.
Choice D: Severe upper abdominal pain. This is a manifestation of gastrointestinal perforation, which is a life-threatening complication of peptic ulcer disease. Peptic ulcer disease is a condition that causes erosion and ulceration of the mucosal lining of the stomach or duodenum. If the ulcer penetrates through the wall of the gastrointestinal tract, it can cause perforation, which is a hole that allows gastric contents to leak into the peritoneal cavity. This can cause peritonitis, which is an inflammation and infection of the peritoneum. Peritonitis can cause severe upper abdominal pain, which may radiate to the shoulder or back. The pain may be sudden, sharp, and constant.
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