Nokea
Select below the 5 findings that require follow-up.
- A. ibuprofen every 8 hours
- B. smokes marijuana 1 or 2 times weekly
- C. client states feeling lightheaded and reports passing out about 1 hour ago
- D. black, liquid stools
- E. crepitus that is worse on the left;
- F. Vital signs: P 110, BP 90/62; no chest pain;
- G. Abdominal pain rated as 4 on a scale of 0-10; one episode of hematemesis;
Correct Answer: A,C,D,F,G
Rationale: A client with hematemesis and black stools is most likely experiencing an acute gastrointestinal (GI) bleed. GI bleeding is a
life-threatening condition that can lead to hemorrhagic shock without immediate intervention. The nurse should immediately
follow up on:
• Chronic NSAID use (eg, ibuprofen), a common cause of drug-induced upper GI bleeds that must be discontinued.
• Hypotension and tachycardia, manifestations of hypovolemia. Hypotension occurs with decreased cardiac output, and
tachycardia is a compensatory mechanism to promote maximum perfusion to vital organs. Because this client has a
history of hypertension, even borderline low blood pressure is considered abnormal.
• Syncope (ie, passing out), a clinical finding associated with hypovolemia caused by decreased perfusion to the brain.
• Hematemesis (ie, vomiting blood), indicative of bleeding in the upper GI tract (eg, stomach ulcers, esophageal varices).
• Dark/black and/or tarry stools, most often associated with upper GI bleeding; blood becomes partially digested as it
passes through the Gl tract, resulting in the dark color.
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Drag words from the choices below to fill in the blank/blanks.The nurse understands that the client is most at risk for------------and------------
- A. Sepsis
- B. Delirium tremens
- C. Respiratory failure
- D. Deep venous thrombosis
- E. Decreased cardiac output
Correct Answer: E,C
Rationale: The nurse understands that the client is most at risk for respiratory failure and decreased cardiac output.
Decreased cardiac output is the most concerning complication in a client with a tension pneumothorax. The trapped air in a tension
pneumothorax causes increased pressure, compressing the affected lung more until it is completely collapsed and then compressing the
heart and great vessels (vena cava, aorta), ultimately inhibiting venous return.
If the pleural pressure continues to increase, eventually the pleural cavity will crowd the trachea, forcing it to deviate (shift) to the unaffected
side where the unaffected lung can be compressed. Clients are at high risk for respiratory failure due to hypoxemia. Without treatment, the
lungs cannot meet the demands for oxygenation and the client will die.
Complete the following sentence by choosing from the lists of options. The nurse should first address the client's -------followed by the client's --------------
- A. Hypovolemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hyperglycemia
Correct Answer: A,D
Rationale: Hyperglycemia in diabetic ketoacidosis (DKA) causes osmotic diuresis that leads to severe dehydration. When hyperglycemia exceeds the
renal threshold of glucose absorption, glucosuria (excretion of glucose in urine) occurs. Water loss is increased due to osmotic diuresis
induced by glucosuria, and extreme dehydration, hypotension, and decreased organ perfusion occur.
The priority intervention in DKA is to initiate an IV fluid bolus with 0.9% sodium chloride followed by insulin administration to lower serum
glucose levels. Rapid fluid resuscitation should occur before insulin infusion because insulin shifts water, potassium, and glucose into the
cells, worsening extracellular dehydration and electrolyte imbalances. Therefore, for clients with DKA, the nurse should first address
hypovolemia followed by hyperglycemia.
The nurse is planning care with the registered nurse. For each potential prescription, click to specify if the prescription is expected or unexpected for the initial care of the client.
- A. Continuous cardiac monitoring
- B. Frequent electrolyte monitoring
- C. Continuous regular insulin IV infusion
- D. Hourly finger-stick blood glucose checks
- E. Nebulized albuterol breathing treatments
- F. 5% dextrose in 0.9% sodium chloride IV infusion
Correct Answer:
Rationale: The priority intervention for diabetic ketoacidosis (DKA) is fluid resuscitation to restore fluid volume and increase organ perfusion. Fluid
resuscitation also treats hypovolemic shock and normalizes electrolyte and blood glucose levels via hemodilution. When planning initial care
for a client with DKA, prescriptions that would be expected include:
• Continuous cardiac monitoring due to the risk for dyshythmias caused by potassium imbalances
• Frequent electrolyte monitoring to assess for electrolyte imbalances from rapid fluid and electrolyte shifts that occur with IV fluid and
insulin administration
• Continuous regular insulin IV infusion of a short-acting insulin used to transport blood glucose into the cells to treat hyperglycemia
and stop ketosis (Glucose levels should be lowered slowly because a rapid decrease in glucose can cause cerebral edema.)
• Hourly finger-stick blood glucose to titrate the insulin dose and monitor glucose levels
Unexpected prescriptions for the initial care of a client with DKA include:
• Albuterol, a beta-adrenergic agonist used to prevent/treat bronchospasm that has the additional effect of decreasing serum potassium
levels. Because the client with DKA is already at risk for hypokalemia due to net potassium deficiency, albuterol increases the client's
risk for dysrhythmias.
• 5% dextrose in 0.9% sodium chloride IV infusion, a sugar-containing solution used to increase blood glucose levels, which would
worsen hyperglycemia
The nurse has reviewed the information from the Laboratory Results., For each client finding below, click to specify if the finding is consistent with the disease process of diabetic ketoacidosis or hyperosmolar hyperglycemic state. Each finding may support more than one disease process.
- A. P 110
- B. pH 7.2
- C. BP 98/58
- D. Poor skin turgor
- E. Fruity breath odor
- F. Positive urine ketones
- G. Kussmaul respiration
Correct Answer:
Rationale: Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are potentially life-threatening complications of diabetes mellitus
(DM). Clients with a decreased level of consciousness, hyperglycemia, electrolyte imbalances, and signs of dehydration should be evaluate
for both DKA and HHS.
DKA is more common in type 1 DM caused by hypoinsulinemia, resulting in hyperglycemia, metabolic acidosis (le, low pH), ketosis (le,
positive ketones in the urine and fruity odor on the breath), and severe dehydration (eg, poor skin turgor, tachycardia, hypotension)
due to osmotic water loss caused by glucosuria. Glucose and potassium are unable to enter the cell due to lack of insulin, causing electroly
imbalances. Kussmaul respirations are deep, rapid breaths that compensate for metabolic acidosis by expelling carbon dioxide (le, an acid)
HHS is characterized by high plasma osmolality and extreme hyperglycemia. Osmolality is increased with dehydration. HHS is more
common in type 2 DM due to a small amount of insulin available to prevent ketosis. Therefore, clients with HHS have a near normal pH leve
and minimal to no urine ketones. Osmotic diuresis and polyuria create a significant fluid volume deficit, causing electrolyte imbalances and
dehydration (eg, poor skin turgor, tachycardia, hypotension), which can lead to hypovolemic shock.
Educational objective:
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.