Nokea
The nurse is caring for a 68-year-old client in the emergency department.
Nurses' Notes,
Emergency Department
1020:
The client reports shortness of breath, a 2-lb weight gain over the past week, and lower extremity swelling. The client
reports slight chest discomfort during activity that is relieved with rest. Medical history is significant for hypertension.
myocardial infarction, heart failure, coronary artery disease, and chronic stable angina. Current medications include
metoprolol, furosemide, potassium chloride, lisinopril, and aspirin. The client takes all medications as prescribed except
one; he states, "I do not take that water pill because I got tired of having to go to the bathroom all the time."
S1 and S2 are present; a prominent S3 is heard. Respirations are labored with inspiratory crackles in the middle and at the
base of the lungs. The abdomen is soft and nontender with normoactive bowel sounds. There is 3+ pitting edema in the
bilateral lower extremities.
Vital Signs,
1020
T ,98.8 F (37.1 C)
P, 60
RR, 24
BP, 168/96
SpO2, 90% on room air
Laboratory Test and Reference Range, 1030
Sodium
136-145 mEq/L
(136-145 mmol/L),
133 mEq/L
(133 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
6.5 mEq/L
(6.5 mmol/L)
BUN
10-20 mg/dL
(3.6-7.1 mmol/L),
22 mg/dL
(7.85 mmol/L)
Creatinine
Male: 0.6-1.3 mg/dL
(53-114.9 umol/L),
1.5 mg/dL
(132.6 umol/L)
Female: 0.5-1.1 mg/dL
(44.2-97.2 umol/L)
The nurse has implemented the prescribed therapies and is now assisting the client to fill out the lunch menu. Which meal choice is best for this client?
- A. Black beans and rice, sliced tomatoes, and a banana
- B. Grilled chicken sandwich, corn on the cob, and applesauce
- C. Hamburger patty on a whole wheat bun with avocado
- D. Salmon, green peas, baked potato, and strawberries
Correct Answer: B
Rationale: This client is experiencing hyperkalemia and should reduce dietary intake of potassium. The preferred meal choice for this client would
include lean meat, such as chicken, that is grilled rather than cooked in oil, and side dishes consisting of fruits and vegetables low in
potassium, such as corn and applesauce (Option 2).
(Options 1, 3, and 4) Beans (a legume), salmon, tomatoes, bananas, potatoes, strawberries, whole wheat products, and avocados are all
high-potassium foods that the client should avoid at this time. Clients with cardiovascular disease should not consume red meat (eg,
hamburger patty) except in limited quantity because it is high in saturated fat.
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The nurse is caring for a 68-year-old client in the emergency department.
Nurses' Notes,
Emergency Department
1020:
The client reports shortness of breath, a 2-lb weight gain over the past week, and lower extremity swelling. The client
reports slight chest discomfort during activity that is relieved with rest. Medical history is significant for hypertension.
myocardial infarction, heart failure, coronary artery disease, and chronic stable angina. Current medications include
metoprolol, furosemide, potassium chloride, lisinopril, and aspirin. The client takes all medications as prescribed except
one; he states, "I do not take that water pill because I got tired of having to go to the bathroom all the time."
S1 and S2 are present; a prominent S3 is heard. Respirations are labored with inspiratory crackles in the middle and at the
base of the lungs. The abdomen is soft and nontender with normoactive bowel sounds. There is 3+ pitting edema in the
bilateral lower extremities.
Vital Signs,
1020
T ,98.8 F (37.1 C)
P, 60
RR, 24
BP, 168/96
SpO2, 90% on room air
Laboratory Test and Reference Range, 1030
Sodium
136-145 mEq/L
(136-145 mmol/L),
133 mEq/L
(133 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
6.5 mEq/L
(6.5 mmol/L)
BUN
10-20 mg/dL
(3.6-7.1 mmol/L),
22 mg/dL
(7.85 mmol/L)
Creatinine
Male: 0.6-1.3 mg/dL
(53-114.9 umol/L),
1.5 mg/dL
(132.6 umol/L)
Female: 0.5-1.1 mg/dL
(44.2-97.2 umol/L)
The nurse receives prescriptions for medications to treat the client's hyperkalemia. For each medication, click to specify if the medication drives potassium from blood into cells, promotes potassium excretion, or stabilizes
myocardial cell membranes.
- A. Furosemide
- B. Albuterol
nebulizer
- C. Calcium gluconate
- D. Insulin and dextrose
Correct Answer:
Rationale: Several medications can rapidly correct a client's hyperkalemia by:
• Driving potassium from blood into cells: The serum potassium level can be temporarily lowered by administering an albuterol
nebulizer and IV insulin. Although albuterol and insulin are not usually administered for this purpose, they also shift potassium from the
extracellular space to the intracellular space. Because insulin transports both glucose and potassium into the cell, dextrose is
administered in combination with insulin to prevent hypoglycemia. Albuterol is not often used alone for hyperkalemia; it is often
administered with insulin and dextrose to improve the potassium-lowering effect.
• Promoting potassium excretion: Administration of loop diuretics (ie, potassium-wasting diuretics such as furosemide) will increase
the amount of potassium excreted into the urine at the loop of Henle and also treat the client's acute fluid volume overload.
• Stabilizing myocardial cell membranes: Administration of calcium gluconate antagonizes potassium and protects the myocardium
from potassium-induced dyshythmias by blocking potassium's effects and reducing myocardial irritability. Calcium gluconate does not
alter serum potassium levels and is usually indicated if there are ECG changes with hyperkalemia.
History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the
roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The
client admits having attempted to jump off the building and wishes the police had not intervened. The
client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The
client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time.
The client reports losing 10 pounds in the past month without trying, difficulty concentrating on tasks,
and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings
of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client
reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19
Laboratory Results
Laboratory Test and Reference Range,Admission
Urine drug screen
Cocaine
Negative
Positive,
Opioid
Negative
Negative,
Amphetamines
Negative
Negative,
Marijuana
Negative
Positive,
Phencyclidine
Negative
Negative,
Benzodiazepines
Negative
Negative,
Barbiturates
Negative
Negative,
Breathalyzer
No alcoho detected
0.00
Complete the following sentence/sentences by choosing from the list/lists of options. he nurse should prioritize interventions for------- due to the client's -----
- A. Malnutrion
- B. Suicidal Behavior
- C. Substance withdrawal
- D. Recent weight loss
- E. Thoughts of self harm
- F. History of cocaine and marijuana use
Correct Answer: B,E
Rationale: The nurse should prioritize interventions for suicidal behavior due to the client's thoughts of self-harm.
This client has several predisposing factors that increase the risk of suicide, including a psychiatric disorder, previous suicide
attempt, stressful life events (eg, divorce), and substance use. However, the strongest single factor predictive of suicide is the
history of a prior suicide attempt (eg, jumping off a building). The nurse should anticipate implementation of suicide
precautions (eg, 1-to-1 observation).
History and Physical
Body System
Findings
General
Client reports a 1-week history of general malaise, fever and chills, night sweats, fatigue, and
poor appetite. Client has poorly controlled hypertension, hypercholesterolemia, and mitral
valve prolapse and regurgitation.
Eye, Ear, Nose, and
Throat (EENT)
Poor dental hygiene. Client reports having 2 teeth extracted 3 weeks ago.
Pulmonary
Vital signs are RR 18 and SpO, 96% on room air. Lungs are clear to auscultation bilaterally.
Cardiovascular
Vital signs are T 100.4 F (38 C), P 105, and BP 140/82. Sinus tachycardia with occasional
premature ventricular contractions on cardiac monitor. S1 and S2 heard on auscultation with
loud systolic murmur at the apex. Peripheral pulses 2+; no edema noted.
Integumentary
Small, erythematous macular lesions on both palms. Thin, brown longitudinal lines on several
nail beds.
The nurse has reviewed the information from the Diagnostic Results and Nurses' Notes. For each finding, click to specify whether the finding indicates that the client's status has not changed or has declined
- A. BP 102/70
- B. T 100.4 F (38 C)
- C. Peripheral pulses 1+
- D. Shortness of breath when recumbent
- E. Scattered crackles on lung auscultation
Correct Answer:
Rationale: Infective endocarditis (E) requires long-term antibiotic therapy (ie, 4-6 weeks). Fever (eg, T 100.4 F [38 C]) can persist for
several days despite appropriate antibiotic therapy.
In addition to the risk for systemic embolism (eg, stroke), clients with IE are at risk for heart failure if the involved valve
becomes dysfunctional. Decreased capillary oxygen saturation, shortness of breath when recumbent, and scattered
crackles on lung auscultation indicate fluid backup in the lungs. In addition, borderline low blood pressure (compared to
uncontrolled high blood pressure at admission) and decreased peripheral pulses (1+ vs 2+ on admission) indicate decreased
cardiac output and are concerning for heart failure.
Nurses' Notes
Outpatient Clinic
Initial
visit
The child recently started attending a new preschool and hit a teacher during lunch. The parent says,
"My
child has never been aggressive before but has always been particular about food."
The client was born at full term without complications and has no significant medical history. The child
started babbling at age 6 months, and the parent reports that the first words were spoken around age 12
months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color.
The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vitals signs are
normal, and the client is tracking adequately on growth curves.
During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow
the parents gaze when the parent points to toys in the office. The child begins screaming and rocking back
and forth when the health care provider comes near.
Laboratory Results
Laboratory Test and
Reference Range
1030
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
110 mg/dL (6.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L)|
133 mEq/L (133 mmol/L)|
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L)
4.5 mEq/L (4.5 mmol/L)
B-type natriuretic peptide
<100 pg/mL
(<100 ng/L)
640 pg/mL (640 ng/L)
Diagnostic Results
Chest X-ray
1030:Mild cardiomegaly
Echocardiogram
1100:Mild left ventricular hypertrophy with left ventricular ejection fraction of 30%
For each finding below, click to specify if the finding is consistent with the expected action of the medication carvedilol, enalapril, or furosemide. Each finding may support more than one medication.
- A. Decreases heart rate
- B. Increases urinary output
- C. Decreases blood pressure
- D. Increases oxygen saturation
Correct Answer:
Rationale: Pharmacologic management of heart failure (HF) focuses on reducing cardiac workload and improving cardiac output.
• Beta-adrenergic antagonists ("beta blockers") (eg, carvedilol) reduce cardiac workload by inhibiting the action of
catecholamines (eg, epinephrine, norepinephrine) on beta-adrenergic receptors in the heart. Beta blockers decrease
myocardial oxygen demand by decreasing blood pressure and decreasing heart rate.
• Angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril) alter the renin-angiotensin-aldosterone system by
inhibiting conversion of angiotensin I to angiotensin II, thereby preventing the release of aldosterone. Aldosterone, an
adrenal steroid hormone, retains sodium and water in addition to promoting vasoconstriction. By reducing circulating
aldosterone, ACE inhibitors promote vasodilation and as a result decrease blood pressure. ACE inhibitors also
decrease ventricular remodeling, an added benefit for clients with HF.
• Loop diuretics (eg, furosemide) prevent reabsorption of sodium and chloride in the kidneys, which increases urine
output and fluid excretion. Decreases in circulating fluid volume will decrease blood pressure and reduce pulmonary
edema (ie, increase oxygen saturation), as well as decrease cardiac preload.
The nurse is caring for a 68-year-old client in the emergency department.
Nurses' Notes,
Emergency Department
1020:
The client reports shortness of breath, a 2-lb weight gain over the past week, and lower extremity swelling. The client
reports slight chest discomfort during activity that is relieved with rest. Medical history is significant for hypertension.
myocardial infarction, heart failure, coronary artery disease, and chronic stable angina. Current medications include
metoprolol, furosemide, potassium chloride, lisinopril, and aspirin. The client takes all medications as prescribed except
one; he states, "I do not take that water pill because I got tired of having to go to the bathroom all the time."
S1 and S2 are present; a prominent S3 is heard. Respirations are labored with inspiratory crackles in the middle and at the
base of the lungs. The abdomen is soft and nontender with normoactive bowel sounds. There is 3+ pitting edema in the
bilateral lower extremities.
Vital Signs,
1020
T ,98.8 F (37.1 C)
P, 60
RR, 24
BP, 168/96
SpO2, 90% on room air
Laboratory Test and Reference Range, 1030
Sodium
136-145 mEq/L
(136-145 mmol/L),
133 mEq/L
(133 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
6.5 mEq/L
(6.5 mmol/L)
BUN
10-20 mg/dL
(3.6-7.1 mmol/L),
22 mg/dL
(7.85 mmol/L)
Creatinine
Male: 0.6-1.3 mg/dL
(53-114.9 umol/L),
1.5 mg/dL
(132.6 umol/L)
Female: 0.5-1.1 mg/dL
(44.2-97.2 umol/L)
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