A client is admitted with suspected meningitis. Which assessment finding requires immediate intervention?

Correct Answer: D

Rationale: The correct answer is D: Seizures. Seizures in a patient with suspected meningitis indicate increased intracranial pressure, which is a medical emergency requiring immediate intervention to prevent brain damage or herniation. Headache (A), fever (B), and nuchal rigidity (C) are common symptoms of meningitis but do not pose an immediate threat to life like seizures do. Addressing the seizures first is crucial to prevent further complications and ensure the patient's safety.

Correct Answer: C

Rationale: The correct answer is C: Crepitus around the insertion site. Crepitus suggests subcutaneous emphysema, which can indicate a pneumothorax or air leak. Immediate intervention is needed to prevent further complications. A: Intermittent bubbling in the water seal chamber is expected and indicates a functioning chest tube system. B: Drainage of 75 ml in the first hour post-insertion is within the normal range and should be monitored. D: Fluctuation of the water level in the water seal chamber with respiration is a normal finding indicating the chest tube is functioning correctly.

Correct Answer: B

Rationale: The correct answer is B: Serum potassium of 6.2 mEq/L. Hyperkalemia is a life-threatening condition in AKI. High potassium levels can lead to cardiac arrhythmias and must be addressed immediately. Choice A is concerning but not as critical as hyperkalemia. Choice C, elevated blood pressure, needs monitoring but does not require immediate intervention. Choice D, elevated serum creatinine, indicates kidney dysfunction but does not pose an immediate threat compared to hyperkalemia.

Correct Answer: D

Rationale: The correct answer is D: Potassium level of 6.5 mEq/L. High potassium levels (hyperkalemia) in CKD patients receiving hemodialysis can lead to serious complications like cardiac arrhythmias or even cardiac arrest. Therefore, it is crucial to report this finding immediately to the healthcare provider for prompt intervention. Explanation for other choices: A: Blood pressure of 150/90 mm Hg - While elevated, this blood pressure reading is not an immediate concern unless accompanied by symptoms like chest pain or shortness of breath. B: Weight gain of 2 pounds since the last dialysis session - While weight gain may indicate fluid retention, it is not an urgent issue unless it is rapid and significant. C: Blood glucose level of 120 mg/dl - A blood glucose level of 120 mg/dl is within the normal range and does not require immediate action in this context.

Correct Answer: C

Rationale: The correct answer is C: Monitor your blood glucose levels regularly. This is important because metformin helps lower blood sugar levels, and monitoring glucose levels helps ensure the medication is effective and the client is not experiencing hypoglycemia or hyperglycemia. Option A is incorrect because metformin should be taken with meals to reduce gastrointestinal side effects. Option B is incorrect as metformin does not typically require fluid restriction. Option D is incorrect as metformin does not affect potassium levels. Regularly monitoring blood glucose levels is crucial for managing type 2 diabetes effectively.