Question

The client is at greatest risk for developing ______

a) Hyponatremia
b) Hyperkalemia
c) Hypocalcemia
d) Hypoglycemia
as evidenced by ______
a) Low potassium levels
b) High blood pressure
c) Elevated temperature
d) Increased respiratory rate
A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG).
Laboratory Results
0630:
Sodium 145 mEq/L (136 to 145 mEq/L)
Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L)
Chloride 116 mEq/L (98 to 106 mEq/L )
BUN 24 mg/dL (10 to 20 mg/dl )
Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L
Total calcium 9.0 mg/dL (9.0 to 10.5 mg/dL)
Phosphate 4.6 mg/dL (3.0 to 4.5 mg/dL)
Glucose 95 mg/dL (74 to 106 mg/dL)
WBC count 9,500/mm3 (5,000 to 10,000/mm3​)
I&O
0700:
4 hr input 400 mL4 hr output 350 mL
1100:
4 hr input 475 mL4 hr output 360 mL
1500:
4 hr input 350 mL4 hr output 375 mL
Vital Signs
0700:
Temperature 37.6° C (99.6° F)
Heart rate 86/min
Respiratory rate 20/min
Blood pressure 115/70 mm Hg
Oxygen saturation 100% on 2 L via nasal cannula
1100:
Temperature 37.2° C (99.0° F)
Heart rate 88/min
Respiratory rate 18/min
Blood pressure 110/72 mm Hg
Oxygen saturation 100% on 2 L via nasal cannula
1500:
Temperature 37.7° C (99.8° F)
Heart rate 80/min
Respiratory rate 20/min
Blood pressure 108/70 mm Hg
Oxygen saturation 100% on 2 L via nasal cannula
Nurses' Notes
0700:
Client alert and oriented x 3. Reports pain as 6 on a scale of 0 to 10. Administered morphine 5 mg IV. Incisional dressing intact. No redness or excessive drainage noted. Urinary catheter patent, draining clear yellow urine. Chest tube patent. No redness or edema noted at chest tube site.

1100:
Client alert and oriented to person, place, and time. Reports pain as 1 on a scale of 0 to 10. Incisional dressing intact. No redness or excessive drainage noted. Urinary catheter patent, draining clear yellow urine. Chest tube patent. No redness or edema noted at chest tube site. Client states their leg muscles are cramping. Assisted the client with range-of-motion exercises to lower extremities. Client tolerated activity.

1500:
Client alert and oriented to person, place, and time. Reports pain as 2 on a scale of 0 to 10. Incisional dressing intact. No redness or excessive drainage noted. Urinary catheter patent, draining clear yellow urine. Chest tube patent. No redness or edema noted at chest tube site. Client continues to report leg muscle cramps.

Medication Administration Record
0700:
0.9% sodium chloride at 150 mL/hr via continuous infusionEnoxaparin 40 mg subcutaneously dailyMorphine 5 mg IV every 4 hr PRN incisional pain

Answer 1

Hyperkalemia is the condition characterized by elevated potassium levels in the blood and can impair the function of various body systems, particularly the heart. The client is at greatest risk for developing hyperkalemia as evidenced by their low potassium level in the laboratory results.

Step-by-step explanation:

Hyperkalemia

is the condition characterized by elevated potassium levels in the blood. It can impair the function of skeletal muscles, the nervous system, and the heart. Hyperkalemia can also result in an inability of cells to repolarize, causing the heart to seize and stop pumping blood, which can be fatal. Symptoms of hyperkalemia may include mental confusion, numbness, and weakened respiratory muscles. In the given scenario, the client is at greatest risk for developing hyperkalemia as evidenced by the low potassium level in their laboratory results.

The client is at greatest risk for developing hypokalemia, as evidenced by low potassium levels. According to the provided laboratory results, the potassium level is 3.2 mEq/L, which is below the normal range of 3.5 to 5.0 mEq/L. This condition can lead to muscle weakness, cramping, and, if severe, could affect the heart rhythm. Nurses' notes also mention the client is experiencing leg cramps, which can be a symptom of low potassium levels.