The nurse has just completed an infusion of a 1-L bolus of 0.9 One hour later, which laboratory result requires immediate nursing action?

Sodium 140 mEq/L.

Lactate 6 mmol/L.

Potassium 3.8 mEq/L.

Creatinine 1.0 mg/dL.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Sodium levels reflect the concentration of solute in the extracellular fluid compartment. The normal range for serum sodium is 135 to 145 mEq/L. A value of 140 mEq/L is perfectly within the normal physiological limits and indicates that the administration of 0.9 percent normal saline, which is an isotonic crystalloid, has not caused an osmotic imbalance or hypernatremia. Therefore, this result does not require any immediate nursing intervention or clinical escalation.

Choice B rationale

Serum lactate is a critical marker of anaerobic metabolism and tissue perfusion. Normal lactate levels are typically less than 2 mmol/L. A level of 6 mmol/L is significantly elevated, indicating severe cellular hypoxia or inadequate tissue oxygenation despite the volume bolus. This suggests that the patient may be in a state of distributive, obstructive, or cardiogenic shock, requiring immediate medical evaluation and potential changes in the resuscitation strategy to prevent organ failure.

Choice C rationale

Potassium is the primary intracellular cation and is vital for maintaining resting membrane potentials in cardiac and skeletal muscle. The normal range for serum potassium is 3.5 to 5.0 mEq/L. A result of 3.8 mEq/L is within the normal range, although it is on the lower end. Since it remains within safe limits, it does not pose an immediate threat of dysrhythmia and does not necessitate urgent action following the infusion of saline.

Choice D rationale

Creatinine is a byproduct of muscle metabolism and is primarily excreted by the kidneys, making it a key indicator of renal function. The normal range for serum creatinine is generally 0.6 to 1.2 mg/dL. A level of 1.0 mg/dL indicates that the kidneys are filtering waste effectively and that there is no immediate evidence of acute kidney injury or impaired renal perfusion following the fluid bolus. Thus, this value is clinically stable and expected.

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Correct Answer is C

Explanation

Choice A rationale

Acute respiratory distress syndrome involves diffuse alveolar damage and noncardiogenic pulmonary edema causing severe hypoxemia. While the pulse oximetry reading of 86 percent is consistent with the hypoxemia found in this syndrome, the clinical hallmark is bilateral infiltrates on a chest radiograph. This condition does not typically cause the mechanical shifting of mediastinal structures. Therefore, the presence of tracheal deviation makes this diagnosis unlikely compared to other obstructive mechanical pathologies of the thoracic cavity.

Choice B rationale

A pulmonary contusion is essentially a bruise of the lung tissue caused by blunt chest trauma, leading to alveolar hemorrhage and edema. This can certainly cause a pulse oximetry reading of 86 percent due to impaired gas exchange at the capillary level. However, a contusion is a parenchymal injury and does not create the positive pressure required to shift the trachea. Normal oxygen saturation is 95 percent to 100 percent, so 86 percent indicates significant respiratory compromise.

Choice C rationale

Tension pneumothorax occurs when air enters the pleural space but cannot escape, causing a rapid buildup of positive pressure. This pressure collapses the affected lung and pushes the mediastinum toward the opposite side, resulting in tracheal deviation. The high intrapleural pressure also compresses the vena cava, reducing venous return and cardiac output. This explains the severe dyspnea and the low pulse oximetry reading of 86 percent seen in this life-threatening medical emergency requiring immediate needle decompression.

Choice D rationale

Flail chest results from multiple rib fractures in two or more places, creating a free-floating segment of the chest wall. This causes paradoxical chest movement where the injured area moves inward during inspiration and outward during expiration. While this can lead to severe dyspnea and low oxygen saturation, it does not create the unilateral tension needed to deviate the trachea. Tracheal deviation is a specific sign of tension within the pleural space rather than chest wall instability.

A. Hypotension, bradycardia, and warm extremities. B. Involuntary spastic movements of the arms and legs. C. Flaccid paralysis and lack of sensation below the level of the injury. D. Loss of voluntary motor control, but presence of reflex activity below the level of the injury.

Correct Answer is C

Explanation

Choice A rationale

Hypotension, bradycardia, and warm, dry skin are the hallmark signs of neurogenic shock, not necessarily spinal shock. Neurogenic shock results from the loss of sympathetic tone and subsequent massive vasodilation following a high cervical or thoracic cord injury. While it can occur simultaneously with spinal shock, the specific physical assessment finding that defines spinal shock is the temporary loss of all neurological activity, including motor, sensory, and autonomic functions, immediately following the traumatic event.

Choice B rationale

Involuntary spastic movements and hyperreflexia are signs of upper motor neuron damage that typically appear weeks or months after the initial spinal cord injury. During the acute phase of spinal shock, the muscles are incapable of such movements because the reflex arcs are entirely suppressed. Spasticity indicates that the period of spinal shock has ended and that the spinal cord below the level of the injury is starting to function independently of brain control.

Choice C rationale

Spinal shock is characterized by the immediate onset of flaccid paralysis and a complete loss of all sensation and reflex activity below the level of the spinal cord injury. This physiological state occurs because of the sudden cessation of impulses from the higher brain centers. It can last from several days to several weeks. The clinical disappearance of spinal shock is marked by the return of the bulbocavernosus reflex and the gradual development of muscle spasticity.

Choice D rationale

This description characterizes the period following the resolution of spinal shock in a patient with a complete spinal cord injury. Once the shock phase passes, reflex activity often returns because the lower motor neurons remain intact, even though voluntary motor control is lost due to the interruption of descending tracts. During the actual state of spinal shock, there is a total absence of reflex activity, making this choice an incorrect assessment for the initial shock phase.

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The nurse has just completed an infusion of a 1-L bolus of 0.9 One hour later, which laboratory result requires immediate nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client with dyspnea, tracheal deviation, and pulse oximetry reading of 86 What is the nurse's interpretation of these findings?

Correct Answer is C

Explanation

A patient with a cervical neck fracture at the C5 level is admitted to ICU following initial treatment in ER. During initial assessment of the patient, the nurse recognizes the presence of spinal shock upon finding:

Correct Answer is C

Explanation

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