Patient Data

During the central line placement, the healthcare provider (HCP) gives the nurse a sample of blood to send to the laboratory.
Which 4 laboratory values would be most important to monitor this client's condition?

Serum osmolality

Calcium

Creatinine

White blood cell count

Glucose

Carbon dioxide

Answer and Explanation

Correct Answer : A,C,D,E

Rationale:
A. Serum osmolality: Monitoring serum osmolality is critical in clients with elevated ICP or neurological injury. Abnormal osmolality can indicate fluid imbalance, which affects cerebral edema and intracranial pressure, guiding fluid management and hyperosmolar therapy if needed.

B. Calcium: While important for overall metabolic and cardiac function, calcium levels do not directly impact acute cerebral perfusion or ICP in this scenario. It is not a priority laboratory value for immediate neurological management.

C. Creatinine: Kidney function must be monitored because impaired renal function affects fluid and electrolyte management, especially with IV therapy and potential osmotic diuretics used to control ICP. Elevated creatinine may alter medication dosing and fluid strategy.

D. White blood cell count: An elevated or decreasing WBC count can indicate infection or sepsis, which can exacerbate cerebral edema or complicate recovery. Infection control is vital in neurosurgical clients with central lines and invasive procedures.

E. Glucose: Hyperglycemia is common in acute neurological injury and can worsen neuronal damage. Maintaining glucose within normal limits supports cerebral perfusion and reduces secondary brain injury.

F. Carbon dioxide: While CO₂ levels affect cerebral blood flow, monitoring arterial blood gases is typically done separately and continuously in critical care. It is important but not one of the top four labs immediately drawn from a routine blood sample in this context.

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Correct Answer is {"dropdown-group-1":"B"}

Explanation

Rationale:

• Systemic inflammatory response syndrome (SIRS): The client presents with fever (101.2° F), tachycardia (126 beats/min), tachypnea (22 breaths/min), and leukocytosis (WBC 20,000/mm³), all of which meet the classic criteria for SIRS. Confusion and recent postoperative status increase suspicion for an infectious trigger. The right knee surgical site shows redness, swelling, and tenderness, suggesting a potential source of infection.

• Transient ischemic attack (TIA): A TIA typically presents with sudden, focal neurological deficits such as weakness, facial droop, or speech disturbances that resolve within 24 hours. While the client is confused, there are no focal deficits reported, and the altered mental status is more likely due to systemic inflammation or infection rather than a cerebral ischemic event. TIA does not explain fever, leukocytosis, or tachycardia.

• Pneumonia: Although the client has mild hypoxia, chest x-ray shows no infiltrates, and lung sounds are diminished but clear. There are no respiratory secretions or cough noted. While infection is suspected at the surgical site, the lungs are not the primary source. Pneumonia does not fully account for the systemic inflammatory response signs observed.

A. Titrate infusion of regular insulin per protocol. B. Monitor daily serum electrolyte levels. C. Check peripheral tissues for edema. D. Enact seizure precautions with seizure pads. E. Implement every 4 hour serial blood sugar levels.

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

Explanation

Rationale:
A. Titrate infusion of regular insulin per protocol: Continuous IV insulin is the cornerstone of HHS management to reduce hyperglycemia gradually. Careful titration prevents rapid shifts in glucose that can cause cerebral edema or other complications.

B. Monitor daily serum electrolyte levels: Electrolyte imbalances, especially potassium, are common in HHS due to dehydration and insulin therapy. Monitoring allows timely replacement and prevents cardiac arrhythmias or neuromuscular complications.

C. Check peripheral tissues for edema: Peripheral edema is not a typical concern in HHS, which primarily causes intracellular dehydration. Monitoring for edema is not a priority in the acute management of HHS.

D. Enact seizure precautions with seizure pads: Severe hyperosmolarity and electrolyte disturbances can precipitate neurological complications, including seizures. Precautions protect the client from injury if a seizure occurs.

E. Implement every 4 hour serial blood sugar levels: Checking blood sugar levels every 4 hours is inadequate for a client receiving a continuous IV insulin infusion for a life-threatening hyperglycemic crisis. Standard of care for HHS requires hourly blood glucose monitoring to allow for the safe titration of the insulin drip and to prevent the complications of hypoglycemia.

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Patient Data During the central line placement, the healthcare provider (HCP) gives the nurse a sample of blood to send to the laboratory. Which 4 laboratory values would be most important to monitor this client's condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"B"}

Explanation

Which intervention(s) should the nurse include in the plan of care (POC) for a client who is admitted with hyperosmolar hyperglycemic syndrome (HHS)? Select all that apply.

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

Explanation

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Patient Data

During the central line placement, the healthcare provider (HCP) gives the nurse a sample of blood to send to the laboratory.
Which 4 laboratory values would be most important to monitor this client's condition?