Complex Care Flashcards

A client with diabetic ketoacidosis (DKA) has been receiving IV insulin and fluids. The nurse notes the client's serum potassium has dropped from 5.0 to 3.1 mEq/L. What is the priority intervention?

Answer: Notify the physician and prepare for potassium replacement

Insulin drives potassium into cells; hypokalemia during DKA treatment can cause life-threatening dysrhythmias, requiring potassium replacement before continuing insulin.

A client with cirrhosis and hepatic encephalopathy is confused and has asterixis. Which intervention is most appropriate to address the encephalopathy?

Answer: Administer lactulose to decrease serum ammonia

Lactulose acidifies the colon, traps ammonia, and promotes its excretion, directly treating the elevated ammonia levels causing hepatic encephalopathy.

A client with a spinal cord injury at C5 develops bradycardia and hypertension, with a blood pressure of 190/110 mmHg, along with pounding headache and profuse sweating above the injury level. The nurse should first:

Answer: Sit the client upright and assess for a noxious stimulus below the injury

These signs indicate autonomic dysreflexia; sitting the client upright to lower blood pressure and identifying/eliminating the triggering noxious stimulus (commonly bladder distension) is the priority.

A nurse is assessing a client 24 hours post-coronary artery bypass graft (CABG). Which finding requires immediate intervention?

Answer: Chest tube output of 250 mL in the last hour

Chest tube output greater than 200 mL/hour post-cardiac surgery indicates excessive bleeding and requires immediate physician notification to assess for cardiac tamponade or surgical hemorrhage.

A client with acute pancreatitis has severe abdominal pain, fever of 38.9°C, and lipase of 800 U/L. Which finding would most indicate a serious complication requiring urgent escalation?

Answer: Grey Turner sign appearing on the flank

Grey Turner sign (flank ecchymosis) indicates retroperitoneal hemorrhage, a severe complication of acute pancreatitis signaling significant internal bleeding.

A client is receiving heparin infusion for deep vein thrombosis. The aPTT result is 120 seconds (therapeutic range 60–100 seconds). What is the appropriate nursing action?

Answer: Reduce the heparin infusion rate per protocol and notify the physician

An aPTT above the therapeutic range indicates supratherapeutic anticoagulation; reducing the rate per protocol and notifying the physician prevents bleeding complications while maintaining anticoagulation.

A client with heart failure has an ejection fraction of 25% and is prescribed carvedilol. The client asks why they need a beta-blocker when it can 'slow the heart down.' What is the best nursing response?

Answer: In heart failure, beta-blockers block chronic sympathetic overstimulation, protecting the heart and improving long-term function

In chronic heart failure, sustained sympathetic activation is harmful; beta-blockers reduce this neurohormonal activation, reverse cardiac remodeling, and improve ejection fraction over time.