A nurse at the emergency department is caring for a female client. Exhibits Which of the following client findings require immediate follow-up by the nurse? Select all that apply.
Explanation & Rationale
A. Capillary refill: Normal (<3 seconds). Not an emergency and does not require immediate follow-up. B. Blood pressure: Stable: 98/64 → 104/70 mm Hg. No signs of shock or hemodynamic instability. C. Potassium: K+ 7.1 mEq/L is critical, life-threatening hyperkalemia. This level can quickly progress to ventricular fibrillation or asystole. Requires immediate emergency treatment, such as IV calcium gluconate (stabilizes cardiac membrane), IV regular insulin + dextrose, and Kayexalate, diuretics (if appropriate), or dialysis D. ECG: ECG shows peaked T waves and widened QRS, which are hallmark signs of impending lethal arrhythmia from hyperkalemia. Worsening QRS widening can lead to ventricular tachycardia which can progress to ventricular fibrillation and cardiac arrest. Requires urgent intervention immediately. E. Oxygen saturation: Normal at 97% on room air. No respiratory distress. F. Breath sounds: Clear bilaterally. No evidence of pulmonary compromise. Not a priority compared to life-threatening hyperkalemia.