Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/VN) who is working on a medical-surgical unit?

Choice A reason:

Watery diarrhea for 3 days is a significant finding that correlates with fluid and electrolyte imbalances. Diarrhea leads to the loss of fluids and electrolytes, which can result in dehydration and electrolyte disturbances such as hypokalemia or hyperkalemia. In this case, the patient’s potassium level is elevated (5.6 mEq/L), which could be a result of the body’s attempt to compensate for the loss of other electrolytes. Diarrhea also contributes to the patient’s weakness and lightheadedness due to dehydration.

Choice B reason:

Chronic kidney disease, which has been managed with diuretics and fluid restrictions, is another critical factor. Chronic kidney disease (CKD) affects the body’s ability to regulate fluid and electrolytes. The use of diuretics can exacerbate electrolyte imbalances, particularly potassium levels. In this scenario, the patient’s elevated potassium level (5.6 mEq/L) is concerning, as CKD patients are at higher risk for hyperkalemia due to decreased renal excretion of potassium. The combination of CKD and recent diarrhea increases the complexity of managing the patient’s fluid and electrolyte balance.

Choice C reason:

Lung sounds are clear is an important assessment finding but does not directly correlate with the primary nursing problem of fluid and electrolyte imbalance. While clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection, this finding does not address the immediate concerns related to fluid loss and electrolyte disturbances. Therefore, it is not a priority in this context.

Choice D reason:

No nausea and vomiting is a relevant finding but does not directly correlate with the primary nursing problem. The absence of nausea and vomiting is positive, as it indicates that the patient is not losing additional fluids and electrolytes through emesis. However, it does not address the significant fluid loss from diarrhea or the electrolyte imbalances that are the primary concerns in this scenario.

Choice E reason:

History of hypertension is a relevant factor in the patient’s overall health status. Hypertension can complicate the management of fluid and electrolyte imbalances, particularly in patients with CKD. The use of antihypertensive medications and diuretics can affect electrolyte levels and fluid balance. In this case, the patient’s blood pressure is slightly low (109/70), which could be related to dehydration from diarrhea and the effects of antihypertensive medications. This history is important for understanding the patient’s baseline and potential complications.

Choice F reason:

Blood urea nitrogen (BUN) is elevated at 30 mg/dL, which is above the normal range (6-24 mg/dL). An elevated BUN level indicates impaired kidney function and can be a sign of dehydration or renal insufficiency. In the context of CKD and recent diarrhea, an elevated BUN suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions.

Choice A: True

Neutropenia, characterized by a low count of neutrophils (a type of white blood cell), significantly increases a patient’s risk for life-threatening infections and sepsis. Neutrophils play a crucial role in the immune system by fighting off infections. When their levels are low, the body becomes more susceptible to infections, which can quickly escalate to sepsis if not promptly treated. Neutropenic sepsis is a severe and potentially fatal condition that requires immediate medical intervention. Patients undergoing treatments like chemotherapy are particularly at risk due to their compromised immune systems.

Choice B: False

The statement that neutropenia does not increase the risk for life-threatening infection and sepsis is incorrect. Neutropenia is well-documented as a major risk factor for severe infections and sepsis. Without adequate neutrophils, the body’s ability to combat pathogens is severely impaired, leading to a higher likelihood of infections that can become systemic and life-threatening. Therefore, it is critical to monitor and manage neutropenic patients closely to prevent and treat infections promptly.

Which statement best describes the nurse’s role in medication reconciliation?