Nokea
A nurse is assessing a client on a medical-surgical unit. Which client is at risk for hypokalemia?
- A. Client with pancreatitis who has continuous nasogastric suctioning
- B. Client with a prescription for an angiotensin-converting enzyme (ACE) inhibitor
- C. Client in a motor vehicle crash who is receiving 2 units of packed red blood cells
- D. Client with uncontrolled diabetes and a serum pH level of 7.33
Correct Answer: A
Rationale: A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia due to the removal of potassium-rich gastric fluids.
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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.
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 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.
A client at risk for developing hyperkalemia states, 'I love fruit and usually eat it every day, but now I can't because of my high potassium level.' How should the nurse respond?
- A. Potatoes and avocados can be substituted for fruit
- B. Fruit is universally high in potassium
- C. Berries, cherries, apples, and peaches are low in potassium
- D. You are correct. Fruit is very high in potassium
Correct Answer: C
Rationale: Not all fruits are potassium-rich. Berries, cherries, apples, and peaches are relatively low in potassium and can be included in the diet of a client at risk for hyperkalemia.
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.