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.

Cerebral edema

Septic shock

Cardiac arrhythmias

Renal failure

Hypotension

Respiratory alkalosis

Answer and Explanation

Correct Answer : A,C,D,E

A. This is a serious complication in DKA, particularly in children, where the shift in osmolality during treatment can lead to fluid shifts into the brain. It can present with neurological deterioration, headache, altered mental status, and even coma.
B.   Septic shock
While infection can precipitate DKA, septic shock itself is not a direct complication of DKA. However, DKA can predispose patients to infections due to impaired immune function, dehydration, and hyperglycemia.
C.   Cardiac arrhythmias
Electrolyte imbalances, particularly hypokalemia or hyperkalemia (depending on treatment phase), can predispose individuals with DKA to cardiac arrhythmias such as ventricular arrhythmias (e.g., ventricular tachycardia) or atrial fibrillation.
D.   Renal failure
Acute kidney injury (AKI) can occur due to dehydration, electrolyte imbalances, and the direct effects of acidosis. However, with prompt and appropriate treatment, renal function typically recovers.
E.   Hypotension
Dehydration and volume depletion are common in DKA due to osmotic diuresis and fluid loss. This can lead to hypovolemic shock and hypotension if not adequately managed with fluid resuscitation.
F Respiratory alkalosis
DKA is associated with metabolic acidosis, not respiratory alkalosis. The body compensates for acidosis by increasing respiratory rate (Kussmaul respirations) to blow off CO2 and normalize pH, but this does not lead to respiratory alkalosis.

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Correct Answer is ["C","D","E","G"]

Explanation

C. The blood pressure readings show significant variability (164/80 mm Hg at 1000, 176/82 mm Hg at 1015, and 110/62 mm Hg at 1200). These fluctuations, especially the higher readings, indicate potential instability and require close monitoring and possibly intervention.
D. The client's pain level is described as 7/10 initially (1000) and decreases to 5/10 after nitroglycerin (1200). Although the pain has decreased, ongoing assessment is necessary to ensure it does not worsen or change in nature.
E. The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes, which are indicative of myocardial ischemia or infarction. This finding requires immediate attention as it suggests ongoing cardiac damage.
G. The troponin T level is elevated at 0.40 ng/mL (normal is less than 0.1 ng/mL). Troponin elevation indicates myocardial injury or infarction and confirms the seriousness of the cardiac event. This finding requires immediate attention to assess the extent of myocardial damage and guide further treatment.

Incorrect Choices
A. While it is slightly elevated, it is not significantly outside the normal range and does not suggest immediate danger or require urgent intervention in the context of the acute cardiac issue. However, monitoring blood glucose levels is important for overall management, especially in a client with diabetes mellitus.
B. The assessment of bowel sounds being present in all 4 quadrants is a normal finding and indicates normal gastrointestinal function. While bowel sounds are important for assessing gastrointestinal health, they are not immediately pertinent to the acute cardiac issue described in the scenario.
F. The nurse notes that lung sounds are clear to auscultation in all lobes, which is a normal finding. Clear lung sounds suggest normal respiratory function and do not require immediate attention in the context of the acute cardiac event described.

A. Administer opioids PO. B. Monitor for hypokalemia as a manifestation of acute rejection. C. Assess urine output hourly. D. Check the client's blood pressure every 8 hr.

Correct Answer is C

Explanation

C. Monitoring urine output is crucial in the early postoperative period after a kidney transplant to assess kidney function and ensure adequate perfusion.

A Managing pain is important, but the administration of opioids should be carefully considered due to their potential to mask symptoms and side effects that could be critical in the postoperative period.

B. While electrolyte imbalances are important to monitor, hypokalemia specifically is not typically associated with acute rejection in the early postoperative period.

D. Blood pressure monitoring every 8 hours may not be sufficient in the immediate postoperative period, especially given the potential for fluid shifts and changes in hemodynamic status.

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ExhibitsThe 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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Naxlex Comprehensive Predictor Exams

Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:

Correct Answer is ["C","D","E","G"]

Explanation

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Correct Answer is C

Explanation

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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.