The nurse assigned to four clients reviews client data at the ...

[DelorasTo]

The nurse assigned to four clients reviews client data at the beginning of the shift. Which information is assessed as the highest priority?
 
  1. Hemoglobin, 12.2 g/dL
  2. Potassium level, 3.6 mEq/L
  3. Pulse oximetry reading, 89
  4. Urine output, 240 mL/8 hr

Question 2

A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders?
 
  1. Hyperthyroidism
  2. Pernicious anemia
  3. Cardiopulmonary disorders
  4. Systemic lupus erythematosus (SLE)

[mceravolo]

Answer to Question 1

3

Rationale: Priorities are classified as high, intermediate, and low. Setting priorities requires a sound nursing knowledge base. The pulse oximetry is well below normal and indicates the high-est priority. Inadequate oxygenation to tissues is life-threatening. The hemoglobin level and the potassium level are within normal range, and these are low priorities. The urine output reading is marginal: 240 mL in an 8-hour period would indicate adequate but low urine output; this presents an intermediate priority.

Answer to Question 2

4

Rationale: An early sign of SLE is the appearance of a butterfly rash across the nose. Hyperthyroidism often leads to moist skin and increased perspiration. Pernicious anemia is exhibited by pale skin. Severe cardiopulmonary disorders may lead to clubbing of the fingers.

[DelorasTo]

Gracias!

[vickyvicksss]

Excellent