Nokea
Select 4 clinical findings that require immediate follow-up.
- A. nausea, vomiting, and abdominal pain
- B. lethargic
- C. Mucous membranes are dry, skin turgor is poor.
- D. missed one dose of levothyroxine
- E. capillary refil time is 4 sec.
Correct Answer: A,B,C,E
Rationale: Type 1 diabetes mellitus is an endocrine disorder characterized by the absence of insulin production in the pancreas. Glucose requires insulin
to be transported from the extracellular space into the cell. Without insulin, glucose continues to circulate in the extracellular space, causing
serum hyperglycemia and intracellular glucose starvation that can lead to diabetic ketoacidosis (DKA).
In DKA, the body breaks down fat for energy (ie, ketosis). This leads to high levels of ketones in the blood, which can cause life-threatening
metabolic acidosis. Clinical findings concerning for DKA require immediate follow-up and include:
• Nausea, vomiting, and abdominal pain—a common presentation of DKA (especially in children) that can be related to delayed gastric
emptying and/or ileus from electrolyte abnormalities and metabolic acidosis
• Neurologic symptoms (eg, lethargy, obtundation) due to progressive hyperglycemia and acidosis
• Signs of dehydration (eg, dry mucous membranes, prolonged P3 sec] capillary refill time) due to osmotic water loss caused by
glucose in the urine
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One hour after chest tube insertion, the client becomes agitated and knocks over the chest tube collection device. The device is damaged. and the tubing becomes disconnected. Which action should the nurse perform first?
- A. Adjust the head of the bed to semi- or high-Fowler position
- B. Notify the health care provider
- C. Obtain a new chest tube collection device
- D. Place the distal end of the chest tube into a bottle of sterile saline
Correct Answer: D
Rationale: If a chest tube becomes disconnected from a damaged drainage system, the priority is to restore the water seal, according to facility policy. A
safe, temporary way to accomplish this is to immerse the distal end of the tube (ie, farthest from the client) into a bottle of sterile saline
or sterile water while someone obtains a new water seal collection device. Some facilities may use shodded (rubber-tipped) hemostats to
temporarily clamp the tube until a new water seal device is obtained. However, clamping the tube can quickly cause a pneumothorax and
should be done only very briefly (Option 4).
The nurse has reviewed the information from the Laboratory Results. Complete the following sentence/sentences by choosing from the list/lists of options.The nurse should prioritize interventions to treat ------------ due to the risk of ---------------------.
- A. Hyperkalemia
- B. Dysrhythmias
- C. Elevated BUN
- D. Seizures
- E. Hyponatremia
- F. Acute kidney injury
Correct Answer: A,B
Rationale: The client's laboratory results show hyperkalemia (ie, high potassium) and decreased kidney function, seen as elevated BUN and creatinine.
The kidneys balance potassium levels by eliminating excess potassium through urine. Clients with heart failure (HF) are at an increased risk fo
hyperkalemia due to poor kidney perfusion from decreased cardiac output and medication adverse effects. This client's decreased kidney
function and home medications, including lisinopril (ACE inhibitor) and supplemental potassium chloride, all increase the risk of hyperkalemia.
Because potassium is responsible for myocardial cell repolarization, hyper- or hypokalemia may lead to life-threatening dysrhythmias.
Therefore, the nurse should prioritize interventions to treat hyperkalemia due to the risk of dysrhythmias.
The nurse has reviewed the information from the Laboratory Results. The nurse suspects that the client may have hyperemesis gravidarum. Which of the following findings support this diagnosis? Select a that apply.
- A. Hematocrit level
- B. Potassium level
- C. TSH level
- D. Urine ketones
- E. Urine specific gravity
Correct Answer: A,B,D,E
Rationale: Hyperemesis gravidarum (HG) is characterized by severe, persistent nausea and vomiting during pregnancy and weight loss of 25% of
prepregnancy weight. The exact cause of HG is unknown, but it is believed that pregnancy-related increases in hormone levels (eg, human
chorionic gonadotropin [hCG]) contribute to the condition. Laboratory findings that assist with the diagnosis of HG include:
• Elevated hematocrit level reflects hemoconcentration, which occurs due to dehydration from excessive vomiting and decreased fluid
intake (Option 1).
• Hypokalemia occurs due to excessive loss of potassium via vomiting and/or insufficient intake of potassium (Option 2).
• Ketonuria (ie, the presence of ketones in urine) results from the metabolism of fat for energy due to a lack of nutritional intake (Option
4).
• High urine specific gravity reflects the concentration of urine; concentrated urine may indicate that the client's volume is depleted,
which is common in HG (Option 5).
Select 5 findings that require further investigation.
- A. unable to lie flat and sleeps in a chair at night
- B. 6-1b (2.7-kg) weight
gain in 1 week - C. increased urinary hesitancy and urgency
- D. SpO2 88% on room air
- E. crackles in bilateral lung
bases;
Correct Answer: A,B,D,E
Rationale: A client with chronic heart failure (HF) who reports worsening fatigue, dyspnea, orthopnea, and peripheral edema is likely
experiencing declining oxygenation due to fluid volume overload. Assessment findings that require further investigation
include:
• Orthopnea: Labored breathing in the supine position is a common manifestation in clients with HF due to pulmonary
edema. Clients with orthopnea often sleep on a chair or on propped-up pillows to decrease work of breathing.
Paroxysmal nocturnal dyspnea, which is waking up in the middle of the night with suffocation due to dyspnea, is another
characteristic finding in HF.
• Crackles on auscultation: Crackles are a manifestation of pulmonary edema caused by fluid in the alveoli. Pulmonary
edema is concerning for worsening HF and impaired gas exchange.
• Peripheral edema and rapid weight gain (ie, >5 Ib/week [2.3 kg/week]): These symptoms are concerning for fluid
volume overload
• Hypoxemia: Decreased capillary oxygen saturation (SpO, <95%) is a sign of inadequate gas exchange. This is most
likely related to pulmonary edema from HF exacerbation.
The nurse has reviewed the information from the Nurses' Notes, Vital Signs, and Laboratory Results.The nurse is reviewing the client's response to potassium-lowering therapies. Which finding is unexpected and requires follow-up by the
nurse?
- A. Blood glucose level and diaphoresis
- B. Blood pressure and heart rate
- C. Crackles and peripheral edema
- D. Serum potassium level
Correct Answer: A
Rationale: Treatment for hyperkalemia includes administration of calcium gluconate, furosemide, albuterol nebulizer, and insulin with dextrose. These
therapies may cause rapid shifts in fluid volume, blood glucose, and serum electrolytes. Insulin shifts available glucose and potassium into
the cell, lowering serum potassium levels; however, too much insulin and not enough dextrose cause hypoglycemia (eg, blood glucose 50
mg/dL [2.7 mmol/L]). Clients with kidney disease have an increased risk of hypoglycemia because insulin may accumulate.
The nurse should understand that a low blood glucose level and symptoms suspicious for hypoglycemia (eg, diaphoresis) require follow-u
to prevent seizures, coma, and death due to lack of circulating glucose (Option 1). This client requires an additional dose of dextrose.
(Option 2) This client's blood pressure is 146/88 mm Hg and heart rate is within normal limits. This is an improvement from the initial blood
pressure and represents a therapeutic response to furosemide administration. Blood pressure should be lowered slowly to avoid hypotensior