Nokea
A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme; [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?
- A. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
- B. Daily weight increase from 55 kg to 57 kg
- C. Heart rate decrease from 100 beats/min to 80 beats/min
- D. Respiratory rate increase from 12 breaths/min to 15 breaths/min
Correct Answer: A
Rationale: ACE inhibitors will disrupt the renin-angiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the client's blood pressure.
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A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.)
- A. A 24-year-old who is malnourished
- B. A 56-year-old with uncontrolled diabetes mellitus
- C. A 45-year-old with hyperparathyroidism
- D. A 62-year-old with chronic renal failure
- E. A 30-year-old using aluminum hydroxide-based antacids
Correct Answer: A,B,E
Rationale: Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled diabetes mellitus, and those who use aluminum hydroxide-based or magnesium-based antacids.
A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?
- A. Assess the client's respiratory rate, rhythm, and depth
- B. Measure the client's pulse and blood pressure
- C. Document findings and monitor the client
- D. Contact the health care provider
Correct Answer: A
Rationale: In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication is respiratory insufficiency, so a respiratory assessment is the priority.
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
- A. Bowel sounds
- B. Depth of respirations
- C. Grip strength
- D. Electrocardiography
Correct Answer: B
Rationale: A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the client's respiratory status first to ensure respirations are sufficient.
A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.)
- A. Electrocardiogram changes
- B. Sodium imbalance
- C. Orthostatic hypotension
- D. Paralytic ileus
- E. Skeletal muscle weakness
Correct Answer: A,D,E
Rationale: Renal failure can lead to hyperkalemia, which causes electrocardiogram changes, paralytic ileus due to impaired gastrointestinal motility, and skeletal muscle weakness.
A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?
- A. A 36-year-old who is prescribed long-term steroid therapy
- B. A 55-year-old receiving hypertonic intravenous fluids
- C. A 75-year-old who is cognitively impaired
- D. A 63-year-old with congestive heart failure
Correct Answer: C
Rationale: Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her fluid needs known is at high risk for dehydration.