Nokea
A nurse develops a plan of care for a client who has a history of hypokalemia. Which interventions should be included in this client's care plan? (Select all that apply.)
- A. Encourage oral fluid intake of at least 2 L/day
- B. Use a draw sheet to reposition the client in bed
- C. Monitor serum potassium levels daily
- D. Provide nonslip footwear for the client to use when out of bed
- E. Rotate the client from side to side every 2 hours
Correct Answer: B,D
Rationale: Clients with long-standing hypokalemia have brittle bones that may fracture easily. Using a draw sheet to reposition and providing nonslip footwear enhance safety and prevent fractures and falls.
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A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?
- A. Encourage oral fluid intake
- B. Connect the client to a cardiac monitor
- C. Assess the client's urine output
- D. Administer oral calcitonin (Calcimar)
Correct Answer: B
Rationale: This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes.
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.
Which meal choice is most appropriate for a client on a low-sodium diet?
- A. Ham sandwich with mustard
- B. Tomato soup with crackers
- C. Spaghetti with meat sauce
- D. Grilled chicken breast with glazed carrots
Correct Answer: D
Rationale: Clients on restricted sodium diets should avoid processed, smoked, and pickled foods and those with sauces and condiments. Foods lowest in sodium include fish, poultry, and fresh produce. Grilled chicken breast with glazed carrots is the lowest in sodium.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
- A. Client receiving 5% dextrose in water (D5W) intravenously and is NPO
- B. A 34-year-old with an infection who is prescribed a sulfonamide antibiotic
- C. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
- D. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)
Correct Answer: A
Rationale: Clients receiving 5% dextrose in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia.
A nurse teaches a client who is at risk for mild hyponatremia. Which statement should the nurse include in this client's teaching?
- A. Weigh yourself every morning and every night
- B. A 3-year-old with a client who is prescribed a sulfonamide antibiotic
- C. Read food labels to determine sodium content
- D. Bake and grill to treat rather than frying it
Correct Answer: C
Rationale: Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate sodium content helps manage sodium intake to prevent hyponatremia. The method of cooking does not significantly alter sodium content unless high-sodium ingredients are added.