The nurse receives the hand-off shift report on assigned clients. Which information is most concerning and prompts the nurse to assess that client first?

Question

Quizplus · Accepted Answer

The nurse should assess first the newly admitted client with gastroenteritis as prolonged vomiting increases the risk for dehydration, acid-base and electrolyte disturbances (eg, orthostatic hypotension, acid loss, hypokalemia, hyponatremia), and potential cardiac dysrthythmias. The client is exhibiting manifestations of hypokalemia, including muscle cramps and muscle weakness. Hypokalemia can lead to dangerous cardiac arrhythmias (Option B). (Option A) A histamine-related reaction (eg, pruritus) is an expected adverse effect associated with the administration of epidural morphine (Astramorph), so this client does not need to be assessed first. An antihistamine such as IV diphenhydramine (Benadryl) may be prescribed to help alleviate itching. (Option C) This client may have been excessively diuresed (eg, with bumetanide [Bumex]) and could have orthostatic hypotension. This client is the second priority. Because the client is in the hospital, the risk of severe hypokalemia is low (as most clients receive potassium supplements), and the client is not exhibiting symptoms of hypokalemia. (Option D) Gross hematuria is an expected manifestation of poststreptococcal glomerulonephritis. It is usually mild and does not require urgent attention. Educational objective: A newly admitted client with gastroenteritis and prolonged vomiting is at risk for acid-base, fluid, and electrolyte disturbances and dehydration related to body fluid and acid loss. The nurse should assess the client for orthostatic hypotension, manifestations of metabolic alkalosis, hypokalemia, hyponatremia, and cardiac dysrhythmias.

The Nurse Receives the Hand-Off Shift Report on Assigned Clients