The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?

Client's serum pH is 7.41

Client has a stage 2 sacral wound

Client requires continuous nasogastric suction

Client has a history of adrenal insufficiency

Answer and Explanation

The Correct Answer is C

A. Client's serum pH is 7.41: This is within the normal range for blood pH (7.35-7.45) and does not specifically indicate a potassium deficit.
B. Client has a stage 2 sacral wound: This is related to skin integrity and does not directly impact potassium levels.
C. Client requires continuous nasogastric suction: Continuous nasogastric suction can lead to the loss of potassium as it removes gastric contents, which may include electrolytes.
D. Client has a history of adrenal insufficiency: While adrenal insufficiency can affect electrolyte balance, continuous nasogastric suction is a more immediate risk for potassium deficit.

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Correct Answer is C

Explanation

A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.

A. The client with a serum phosphorus of 4.5 mg/dL that requires assistance with planning their meals B. The client with a serum magnesium of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes C. The client with a serum potassium of 5.3 mEq/L and is scheduled for hemodialysis in three hours D. The client with a serum sodium of 145 mEq/L who is complaining of a dry mouth and wants a glass of water

Correct Answer is B

Explanation

A. The client with a serum phosphorus of 4.5 mg/dL that requires assistance with planning their meals: A serum phosphorus level of 4.5 mg/dL is within the normal range, and assistance with meal planning is a lower priority compared to the other situations.
B. The client with a serum magnesium of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes: This client has hypomagnesemia, which can lead to severe complications like seizures or cardiac arrhythmias. Immediate attention is necessary due to the symptoms and the critically low magnesium level.
C. The client with a serum potassium of 5.3 mEq/L and is scheduled for hemodialysis in three hours: This potassium level is slightly elevated, but the scheduled hemodialysis suggests the issue will be addressed soon.
D. The client with a serum sodium of 145 mEq/L who is complaining of a dry mouth and wants a glass of water: A serum sodium of 145 mEq/L is on the high end of normal; the client's dry mouth is concerning but not as urgent as the issues presented by the hypomagnesemia.

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The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

After receiving the change of shift report, the nurse reviews the electronic health record for each client. What client should the nurse see first?

Correct Answer is B

Explanation

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