Patho Patho #13

Question

Which client should the nurse prioritize during morning assessments?

Answers

  1. A client with chronic obstructive pulmonary disorder (COPD) who had a PaCO2 level of 50mg/dl.
    • Rationale:

      This answer choice is not correct because a client with COPD is expected to have an elevated PaCO2 level. This client is not the nurse’s priority.

  2. A client with a Ca+ level of 6.5 mg/dL who is reporting dyspnea without exertion.
    • Rationale:

      This answer is correct because a client with a critically low Ca+ level reporting dyspnea is probably experiencing laryngospasms. This client should be assessed immediately by the nurse.

  3. A client admitted with congestive heart failure who has a BNP level of 420.
    • Rationale:

      This answer choice is not correct because a client with known congestive heart failure is expected to have an elevated BNP level. This client is not the nurse’s priority.

  4. A client with pneumonia who has an oxygen saturation level of 95% on 2 LPM per bi-nasal cannula.
    • Rationale:

      This answer choice is not correct because a client with pneumonia with an O2 saturation of 95% is stable. This client is not the nurse’s priority. A client reporting dyspnea with hypocalcemia should be assessed immediately.

Overview

The focus of this question is prioritizing the care for four different clients. The most critically ill client is the one who is reporting shortness of breath due to hypocalcemia. Dyspnea caused by hypocalcemia is caused by laryngospasms.

Explanation

Learning Outcomes

When calcium levels are low, laryngospasms is a very critical potential complication. A normal calcium level ranges from 8.5 mg/dL- 10.5 mg/dL so a calcium level of 6.5 mg/dL is critically low. Critically low calcium levels can lead to laryngospasms which would cause the client to report dyspnea.

Test Taking Tip

Always refer to A-B-C. Dyspnea reveals an issue with the client’s airway and breathing and is therefore the nurse’s priority.

Video Rationale