The nurse assesses a patient who has been hospitalized for 2 ...

[K@]

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO.
 
  Which assessment finding would be a priority for the nurse to report to the health care provider?
  a. Oral temperature of 100.1 F
  b. Serum sodium level of 138 mEq/L (138 mmol/L)
  c. Gradually decreasing level of consciousness (LOC)
  d. Weight gain of 2 pounds (1 kg) above the admission weight

Question 2

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
 
  a. K+ 3.4 mEq/L (3.4 mmol/L)
  b. Ca+2 7.8 mg/dL (1.95 mmol/L)
  c. Na+ 154 mEq/L (154 mmol/L)
  d. PO4-3 4.8 mg/dL (1.55 mmol/L)

[zogaridan]

Answer to Question 1

ANS: C
The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.

Answer to Question 2

ANS: C
The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal.

[K@]

Correct answers!

[zogaridan]

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