Page 71 - Saunders Comprehensive Review For NCLEX-RN

Which of the findings would be essential to follow up on?
Click on the finding that would be essential to follow up on to highlight it.
Highlight only findings that require follow-up. To deselect, click the finding
again.

Answer:

With newly diagnosed type 2 diabetes mellitus, the client is at risk for diabetic
ketoacidosis or hyperglycemic hyperosmolar non-ketotic syndrome, both of which
can lead to hypovolemia and shock. The blood pressure has remained stable for this
client but is declining. At this time, it does not require further follow-up. The pulse
rate has increased significantly since admission, and is a sign of hypovolemia, which
is a finding that should be addressed. The respiratory rate is slightly elevated and
should be addressed early on because this is a sensitive indicator of fluid status. The
capillary glucose and serum glucose levels at each of the timepoints has been
elevated, and an intervention is required to address this abnormality. The serum
potassium level was within the normal range initially but has decreased since
admission and is now at a critical level. This could be due to the client’s treatment,
which likely involves insulin. This requires follow-up because of the risks associated
with hypokalemia. The urine output has steadily decreased and could be an
indicator of hypovolemia, and therefore requires follow-up. The temperature is
normal and does not require follow-up.

Matrix Items
These items present data regarding a client, and may ask the student to select actions
that are essential, nonessential, and contraindicated. See Box 1-16 for an example.

Box 1-16
NGN Item: Matrix Item

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