The nurse is renewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L, Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

Obtain a 12 lead ECG

Request an electroencephalogram (FEC)

Assess for Chvostek's sign

Obtain a chest X-ray.

Answer and Explanation

The Correct Answer is A

A) Obtain a 12-lead ECG:
The client’s potassium level of 6.6 mEq/L is significantly elevated which places the patient at risk for cardiac arrhythmias. Elevated potassium levels can cause dangerous changes in the electrical activity of the heart, leading to peaked T waves, widened QRS complexes, and even cardiac arrest. A 12-lead ECG is necessary to assess the heart's electrical activity and to identify any potential arrhythmias

B) Request an electroencephalogram (EEG):
An EEG is used to assess brain activity and is typically indicated for conditions such as seizures or epilepsy. This client’s laboratory findings do not suggest a neurological concern that would warrant an EEG.

C) Assess for Chvostek's sign:
Chvostek's sign is used to assess for hypocalcemia or tetany, where a twitching of the facial muscles occurs upon tapping the facial nerve. However, the client’s primary issue here is elevated potassium levels, which are a more immediate concern than hypocalcemia. Hyperkalemia can have more severe and urgent consequences, particularly for the heart, so Chvostek's sign is not the priority at this time.

D) Obtain a chest X-ray:
A chest X-ray is not indicated based on the client’s current electrolyte imbalance or renal failure status. While a chest X-ray may be useful for various other concerns, the client’s elevated potassium level is the primary issue, and the priority intervention is to assess and manage the potential for cardiac arrhythmias with a 12-lead ECG.

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Correct Answer is B

Explanation

A. 2-6 hours before meals:
This timeframe is too long for rapid-acting insulin like Lispro. Rapid-acting insulins, such as Lispro, begin to work quickly after administration, typically within 15 minutes, and peak around 1 to 2 hours after injection. Administering it 2-6 hours before meals would not align with the timing of food intake and would likely lead to hypoglycemia before the meal. Timing of rapid-acting insulin should be closer to the meal to match the rise in blood glucose levels that occurs after eating.

B. Lispro lasts 24 hours and does not have to be timed with meals:
This statement is incorrect. Lispro is a rapid-acting insulin, and its duration of action is much shorter than 24 hours, typically lasting about 3-5 hours. It is crucial to time the administration of Lispro with meals to match its peak action with the rise in blood glucose levels after eating. A long-acting insulin would be the type that lasts for 24 hours, but that is not the case with Lispro.

C. 15-30 minutes before meals:
Lispro is a rapid-acting insulin, and its onset of action occurs within 15 minutes after injection. It is most effective when administered within 15-30 minutes before the start of a meal, as it peaks in about 1-2 hours and works to regulate blood glucose levels during and after the meal. This timing ensures that insulin works in concert with the rise in blood glucose following food intake, helping prevent hyperglycemia.

D. 60 minutes before meals:
Administering Lispro 60 minutes before a meal is too early. Rapid-acting insulins, such as Lispro, begin working quickly and reach peak action within 1-2 hours. If administered too far in advance, there is a risk that the insulin may have peaked before the meal, leading to a potential drop in blood glucose levels before the meal is consumed. This could result in hypoglycemia. Therefore, administering it closer to the meal, within 15-30 minutes, is the optimal timing.

A. Impaired perineal skin intergrity B. Fluid and electrolyte imbalances C. Pain related to abdominal cramping D. Protein-calorie malnutrition

Correct Answer is B

Explanation

A. Impaired perineal skin integrity:
While impaired perineal skin integrity is a concern for clients with severe diarrhea, it is not the priority risk in this case. Diarrhea can lead to irritation and breakdown of the skin, especially in the perineal area, but this can generally be managed with proper skin care and barrier creams. While important, this is not the most critical issue at the moment.

B. Fluid and electrolyte imbalances:
The priority risk for a client with an acute exacerbation of Crohn's disease and severe diarrhea is fluid and electrolyte imbalances. Diarrhea causes significant fluid loss, which can lead to dehydration and imbalances in electrolytes such as sodium, potassium, and chloride. These imbalances can result in life-threatening complications like hypovolemic shock, arrhythmias, and kidney failure. Therefore, ensuring adequate fluid and electrolyte replacement is the top priority in this situation.

C. Pain related to abdominal cramping:
While pain due to abdominal cramping is common in Crohn's disease, it is not the most immediate risk in this scenario. Pain management is important for comfort, but the risk of dehydration, electrolyte imbalances, and potential shock due to fluid loss takes precedence. Pain relief can be addressed after managing the more critical issues.

D. Protein-calorie malnutrition:
Protein-calorie malnutrition is a concern for patients with Crohn's disease, especially with chronic disease or malabsorption. However, in the context of an acute exacerbation with severe diarrhea, the immediate concern is fluid and electrolyte imbalance. Nutritional concerns, including malnutrition, are important for long-term management, but the priority in this acute phase is stabilizing the client’s fluid status to prevent further complications.

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The nurse is renewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L, Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

Nursing Test Bank

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