A client with diabetes insipidus is admitted due to a pituitary tumor. What complication should the nurse monitor for closely?

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Monitor for hypokalemia. Diabetes insipidus, caused by a pituitary tumor, leads to excessive urination and subsequent loss of water and electrolytes, particularly sodium and potassium. As a result, hypokalemia (low potassium levels) is a common complication that the nurse should closely monitor for. Option A) Monitoring for elevated blood pressure is not directly related to the pathophysiology of diabetes insipidus caused by a pituitary tumor. While diabetes insipidus can lead to dehydration, impacting blood pressure, it is not the most significant complication to monitor in this case. Option B) Monitoring for ketonuria is more relevant in conditions like diabetic ketoacidosis, which is not typically associated with diabetes insipidus. Option C) Monitoring for peripheral edema is more commonly seen in conditions like heart failure or renal issues, rather than diabetes insipidus. Understanding the specific electrolyte imbalances and complications associated with diabetes insipidus due to a pituitary tumor is crucial for nurses caring for these patients. Monitoring potassium levels closely can prevent potentially serious consequences such as cardiac arrhythmias and muscle weakness.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Diminished left lower lobe sounds. This finding warrants immediate intervention because it indicates a potential complication such as a possible pneumothorax, which can be life-threatening for the client with ARDS. As the left lower lobe sounds are diminished, it suggests a problem with ventilation in that area, requiring prompt assessment and action. Option A) Assess the client's lung sounds bilaterally, while important, does not specifically address the critical issue of diminished sounds in a specific lobe. Option C) Monitoring ventilator settings for changes in oxygen levels is essential but does not directly address the urgent need for intervention indicated by diminished lung sounds. Option D) Increased sputum production and shortness of breath are concerning symptoms but do not address the immediate need for intervention indicated by diminished left lower lobe sounds. Educationally, understanding the significance of assessing lung sounds comprehensively and recognizing specific abnormal findings is crucial for nurses caring for clients with ARDS. This knowledge can help prioritize interventions and prevent potential complications in critically ill patients.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Fine hand tremors noted after starting the medication. It is crucial to report this finding to the healthcare provider because hand tremors can be an early sign of lithium toxicity, which can be a serious and potentially life-threatening side effect of lithium therapy. Option A, a serum lithium level of 1.2 mEq/L, is within the therapeutic range for lithium and does not indicate toxicity. Option C, a blood pressure of 110/60 mmHg, is within normal limits and not directly related to lithium therapy. Option D, a serum sodium level of 140 mEq/L, is also within normal limits and not a priority concern when compared to potential lithium toxicity. Educationally, understanding the side effects and monitoring parameters of lithium therapy is essential for nurses caring for clients with bipolar disorder. Recognizing early signs of lithium toxicity, such as hand tremors, and knowing when to escalate concerns to the healthcare provider is critical in promoting patient safety and optimal outcomes.

Correct Answer: C

Rationale: In the context of a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, the nurse should assess the client's capillary blood glucose level first (Option C). This is crucial because hyperglycemia can lead to serious complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, which require immediate intervention. Monitoring the blood glucose level helps in determining the severity of hyperglycemia and guides appropriate treatment. Assessing for signs of infection (Option A) is important in a postoperative client, but hyperglycemia needs immediate attention to prevent complications specific to diabetes. Monitoring fluid intake and output (Option B) is essential for overall assessment but does not directly address the priority of managing hyperglycemia. Assessing serum potassium level (Option D) is important, but correcting hyperglycemia takes precedence to prevent electrolyte imbalances associated with uncontrolled diabetes. In an educational context, understanding the priority assessment in a client with diabetes experiencing postoperative hyperglycemia is crucial for nurses to provide timely and effective care. This scenario highlights the significance of prioritizing assessments based on the client's condition and the potential risks associated with uncontrolled hyperglycemia.

Correct Answer: A

Rationale: In this scenario, the nurse's primary concern should be monitoring for signs of a pulmonary embolism (PE) when a client reports unilateral leg swelling after a long flight. This is because deep vein thrombosis (DVT) is a common risk associated with prolonged immobility during flights, and a PE is a serious complication of a DVT where a blood clot travels to the lungs, potentially causing life-threatening consequences. Option A is correct because it directly addresses the most critical and time-sensitive complication in this situation. Option B, assessing for signs of dehydration, is less relevant in this context as unilateral leg swelling after a long flight is more indicative of a circulatory issue rather than dehydration. Option C, monitoring for signs of compartment syndrome, is also not the priority as compartment syndrome typically presents with severe pain, pallor, pulselessness, paresthesia, and paralysis, which are not mentioned in the scenario. Option D, checking the client's oxygen saturation levels, is not the immediate concern when a client presents with unilateral leg swelling after a long flight, as the primary focus should be on ruling out a PE. Educationally, understanding the priority of nursing assessments based on the client's presentation is crucial for providing safe and effective care, especially in high-risk situations like post-flight leg swelling. Nurses must be able to recognize potential complications promptly to initiate appropriate interventions and prevent adverse outcomes.