The nurse determines that this client’s priority problem is:
A.
Fluid volume deficit as a result of fluid loss
B.
Sodium imbalance due to antibiotic therapy
C.
Potassium imbalance due to infection
D.
Fluid volume excess due to fluid administration
The Correct answer and Explanation is:
To determine the priority problem for a client, it’s essential to assess the clinical context and the most urgent issue impacting the client’s health. Let’s break down each option to understand which might be the most critical concern:
A. Fluid volume deficit as a result of fluid loss Fluid volume deficit typically results from conditions such as vomiting, diarrhea, or excessive diuresis. Symptoms may include hypotension, tachycardia, dry mucous membranes, and decreased urine output. If a client is showing signs of dehydration and fluid loss, this can lead to serious complications, including renal failure, shock, and electrolyte imbalances. This can be a critical concern but may not always be the highest priority depending on the overall clinical picture.
B. Sodium imbalance due to antibiotic therapy Sodium imbalances can arise from various factors, including certain medications. Antibiotics can sometimes lead to alterations in sodium levels, either through direct effects or secondary to fluid shifts and other imbalances. Symptoms of sodium imbalance (hyponatremia or hypernatremia) can include confusion, muscle twitching, seizures, and changes in mental status. While important, a sodium imbalance might not always be the immediate priority unless it is severely impacting the client’s neurological status.
C. Potassium imbalance due to infection Potassium imbalances (either hyperkalemia or hypokalemia) are critical because they directly affect cardiac function. Infections can lead to alterations in potassium levels due to shifts in potassium between intracellular and extracellular compartments or through effects on renal function. Symptoms of potassium imbalance include arrhythmias, muscle weakness, and fatigue. Given its direct impact on cardiac function, potassium imbalance can be a significant priority.
D. Fluid volume excess due to fluid administration Fluid volume excess can occur with excessive fluid administration or impaired fluid excretion. It can lead to symptoms like edema, hypertension, and shortness of breath. In severe cases, it can result in pulmonary edema and heart failure. Management of fluid balance is crucial to prevent such complications, making fluid volume excess a significant concern in critically ill patients.
Correct Answer: C. Potassium imbalance due to infection
Explanation: Potassium imbalances are critical due to their direct impact on cardiac function and overall cellular activity. Infections can disrupt normal potassium levels, and both hypokalemia and hyperkalemia can lead to severe consequences, including life-threatening cardiac arrhythmias. Immediate treatment is necessary to restore normal potassium levels and prevent complications. While fluid volume issues and sodium imbalances are also important, the urgency of managing potassium levels, especially in the context of infections, makes it the priority in this scenario