The nurse is caring for a client who has been hospitalized for 2 days and is receiving normal saline IV at 100 mL/hour, has a nasogastric tube to low suction, and is NPO. Which of the following assessment findings by the nurse is the priority to reporttothehealth care provider?
A)Serum sodium level of 138 mmol/L
B)Gradually decreasing level of consciousness (LOC)
C)Oral temperature of 37.8°C (100°F) with bibasilar lung crackles
D)Weight gain of 1 kg above the admission weight

Question

Quizplus · Accepted Answer

The client's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider 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.

The Nurse Is Caring for a Client Who Has Been