33. A nurse is reviewing the laboratory values for a group of clients in a psychiatric emergency department. Prioritize each laboratory result from most to least important to report to a physician.
33. A nurse is reviewing the laboratory values for a group of clients in a psychiatric emergency department. Prioritize each laboratory result from most to least important to report to a physician.
. The client taking clozapine (Clozaril) with a WBC count of <3000/mm3.
. The client with bipolar disorder and a lithium level of 1.6 mEq/L.
. The client with a blood alcohol level of 0.08%.
. The client with schizoaffective disorder and a potassium level of 6.0 mEq/L.
Test-Taking Tip
Remember priorities and to rank according to a threat to the client's physiological integrity.
Content Area: Mental Health, Management of Care; Integrated Process: Nursing Process, Planning; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
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Answer 4 is correct because the nurse would report the laboratory value of the fourth client with a potassium level of 6.0 mEq/L first because this is a critical value (e.g., dysrhythmias) and needs to be reported immediately to the physician. Answer 1 is correct because the nurse would report the first client with the WBC count at <3,000/mm3second because the client who is taking clozapine (Clozaril) is at risk for agranulocytosis (e.g., neutropenia). Answer 2 is correct because the nurse would attend to the second client with the lithium level of 1.6 mEq/L third because this is just over the therapeutic level (1.5 mEq/L) and the client could experience more severe side effects (e.g., marked tremor). Answer 3 is correct because the nurse would prioritize the third client with the blood alcohol level of 0.08% last because the level does show intoxication, but it is not at a dangerous level (e.g., 0.30%).