Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?

Reference Range:

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
.

Surgical consent form is not signed.

Client's pulse oximeter reading is 96%.

Preoperative chest x-ray report is not available.

Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L).

Answer and Explanation

The Correct Answer is D

A.   The surgical consent form is crucial for ensuring that the client is informed about the procedure and agrees to it. While it's critical for legal and ethical reasons, this issue can often be resolved relatively quickly by having the client sign the form or addressing it with the surgeon.
B.   A pulse oximeter reading of 96% indicates that the client's oxygen saturation is within a generally acceptable range (normal is usually 95% to 100%). This reading suggests that the client's oxygen levels are adequate and typically would not require immediate action.
C.   The absence of a preoperative chest x-ray report can be significant, especially if the client has underlying respiratory or cardiac conditions. However, the immediate need for action depends on the urgency and the reason the x-ray was ordered.
D.   A serum potassium level of 2.8 mEq/L is critically low. The normal reference range is 3.5 to 5 mEq/L. Hypokalemia (low potassium) can lead to severe complications, including cardiac arrhythmias and muscle weakness, which can significantly impact the client's ability to safely undergo surgery. This condition requires immediate attention to correct the electrolyte imbalance before proceeding with the surgical procedure.

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Correct Answer is B

Explanation

A. This is a valid nursing problem and directly related to the client's condition. However, while fatigue is a significant concern, it is often a symptom of other underlying issues.

B. This is the highest priority nursing problem. Pain is a primary symptom of acute RA exacerbation and significantly impacts the client's quality of life, mobility, and overall well-being. Addressing pain is crucial for immediate comfort and to facilitate other interventions.
C. This is also a valid nursing problem, directly linked to the client's symptoms. However, it is a consequence of the pain, not the primary issue. Addressing the pain will improve mobility.
D. This is a potential long-term concern but not the highest priority at this acute stage. The client's immediate needs related to pain and mobility are more pressing.

A. Calcium level 7.2 mg/dL (1.8 mmol/L). B. Potassium level 3.8 mg/dl. (3.8 mmol) C. Sodium level 140 mEq/L (140mmol/L). D. Oxygen saturation level 97%.

Correct Answer is A

Explanation

A. This calcium level is below the normal reference range (8.4 to 10.6 mg/dL or 2.10 to 2.50 mmol/L), indicating hypocalcemia. Calcium plays a crucial role in cardiac muscle contraction and electrical conduction. Low calcium levels can lead to various cardiac dysrhythmias, including prolonged QT intervals and increased risk of ventricular arrhythmias.

B. This potassium level falls within the normal range (3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L). Potassium is essential for maintaining normal cardiac rhythm, but a level of 3.8 mg/dL is not abnormal and, therefore, is less likely to be the cause of a dysrhythmia compared to abnormal levels.
C. This sodium level is within the normal reference range (136 to 145 mEq/L or 136 to 145 mmol/L). Sodium levels typically do not directly cause dysrhythmias unless they are extremely high or low, which is not the case here. Thus, a sodium level of 140 mEq/L is not likely to be the primary contributor to the dysrhythmia.
D. This oxygen saturation level is considered normal (95% to 100%). While oxygenation is critical for overall heart function and can influence cardiac health, a saturation level of 97% is not likely to be a direct cause of a dysrhythmia, especially if it falls within the normal range.

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Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] .

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Explanation

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Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?

Reference Range:

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
.