Nokea
A client with chronic renal failure is being treated with sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?
- A. Hyponatremia.
- B. Hypokalemia.
- C. Hyperkalemia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: The correct answer is C: Hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) is used to treat high potassium levels (hyperkalemia) by exchanging sodium ions for potassium ions in the large intestine, which is then eliminated through the feces. Therefore, the nurse should monitor the client for changes in potassium levels to ensure the effectiveness of the treatment. Choices A, B, and D are incorrect because sodium polystyrene sulfonate (Kayexalate) is not associated with causing hyponatremia, hypokalemia, or hypocalcemia.
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What do crackles heard on lung auscultation indicate?
- A. Cyanosis.
- B. Bronchospasm.
- C. Airway narrowing.
- D. Fluid-filled alveoli.
Correct Answer: D
Rationale: Crackles heard on lung auscultation are caused by the popping open of small airways that are filled with fluid. This is commonly associated with conditions such as pulmonary edema, pneumonia, or heart failure. Cyanosis (Choice A) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, not directly related to crackles. Bronchospasm (Choice B) refers to the constriction of the airway smooth muscle, causing difficulty in breathing but does not typically produce crackles. Airway narrowing (Choice C) can lead to wheezing but is not directly linked to crackles heard on auscultation.
In a patient with anemia, which of the following is the primary symptom to assess?
- A. Fever.
- B. Chest pain.
- C. Shortness of breath.
- D. Muscle cramps.
Correct Answer: C
Rationale: The correct answer is C: Shortness of breath. In a patient with anemia, the primary symptom to assess is shortness of breath. Anemia leads to a reduced oxygen-carrying capacity of the blood, resulting in tissues not receiving adequate oxygen. This can manifest as shortness of breath, especially during physical exertion. Fever (Choice A), chest pain (Choice B), and muscle cramps (Choice D) are not typically primary symptoms of anemia. Fever may suggest an infection, chest pain can be indicative of cardiac issues, and muscle cramps may be related to electrolyte imbalances or neuromuscular disorders.
The nurse is caring for a client who is scheduled for hemodialysis. Which of the following laboratory values should the nurse monitor closely before, during, and after the procedure?
- A. Hemoglobin level.
- B. Blood urea nitrogen (BUN) level.
- C. Creatinine level.
- D. Serum potassium level.
Correct Answer: D
Rationale: The correct answer is D: Serum potassium level. Before, during, and after hemodialysis, monitoring the serum potassium level is crucial to prevent hyperkalemia, a potentially life-threatening complication. Hemodialysis is done to remove waste products and excess electrolytes like potassium from the blood. Monitoring other laboratory values like hemoglobin, BUN, and creatinine is important in assessing kidney function and anemia, but serum potassium level requires close monitoring during hemodialysis due to the risk of rapid shifts that can lead to cardiac arrhythmias.
To reduce the risk of pulmonary complications for a client with ALS, which intervention should the nurse implement?
- A. Perform chest physiotherapy
- B. Teach the client breathing exercises
- C. Initiate passive range of motion exercises
- D. Establish a regular bladder routine
Correct Answer: A
Rationale: Performing chest physiotherapy is the most appropriate intervention to reduce the risk of pulmonary complications in clients with ALS. Chest physiotherapy helps mobilize and clear respiratory secretions, improving lung function and reducing the risk of complications such as pneumonia. Teaching breathing exercises (Choice B) may be beneficial for some clients, but chest physiotherapy is more specifically targeted at managing pulmonary issues in ALS. Initiating passive range of motion exercises (Choice C) and establishing a regular bladder routine (Choice D) are important interventions in ALS care but are not directly related to reducing the risk of pulmonary complications.
Laboratory findings indicate that a client's serum potassium level is 2.5 mEq/L. What action should the nurse take?
- A. Inform the healthcare provider of the need for potassium replacement.
- B. Prepare to administer a glucose-insulin-potassium replacement.
- C. Change the plan of care to include hourly urinary output measurement.
- D. Instruct the client to increase daily intake of potassium-rich foods.
Correct Answer: A
Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. The immediate action the nurse should take is to inform the healthcare provider of the need for potassium replacement. Option B, preparing to administer glucose-insulin-potassium replacement, is not the first-line intervention; it may be considered in specific situations but requires a healthcare provider's prescription. Option C, changing the plan of care to include hourly urinary output measurement, is not the priority when managing critically low potassium levels. Option D, instructing the client to increase daily intake of potassium-rich foods, is not appropriate in this acute situation where immediate intervention is needed to address the dangerously low potassium level.