Recognition Of Acute And Chronic Illness Practice Test

A 45-year-old client with type 1 diabetes mellitus reports 24 hours of vomiting and flu-like symptoms and has been unable to keep fluids down. Assessment: temperature 38.1°C (100.6°F), heart rate 124/min, respiratory rate 28/min with deep respirations, blood pressure 88/54 mm Hg, oxygen saturation 98% on room air; capillary blood glucose 520 mg/dL; labs: anion gap 22, bicarbonate 12 mEq/L, potassium 5.8 mEq/L. Which data indicates an acute change that requires IMMEDIATE action?

A 71-year-old client with COPD is admitted for acute exacerbation; baseline oxygen saturation is 88–92% on home oxygen. Current assessment: heart rate 102/min, respiratory rate 26/min, blood pressure 140/82 mm Hg, oxygen saturation 90% on 2 L/min; client reports a new severe headache and increasing sleepiness; arterial blood gas: pH 7.28, PaCO2 68 mm Hg, PaO2 60 mm Hg, HCO3− 30 mEq/L. What is the PRIORITY finding to report to the RN?