Nokea
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.
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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.
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 nurse evaluates a client who is being treated for hypokalemia. Which findings indicate that treatment is effective? (Select all that apply.)
- A. Respiratory rate of 8 breaths/min
- B. Strong, productive cough
- C. Absent deep tendon reflexes
- D. Active bowel sounds
- E. U waves present on the ECG
Correct Answer: B,D
Rationale: A strong, productive cough indicates improved muscle strength, and active bowel sounds suggest resolution of hypokalemia-related gastrointestinal issues.
After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?
- A. Toasted English muffin with butter and blueberry jam, and tea with sugar
- B. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
- C. Sausage, whole-wheat toast, half cup of raisins, and a glass of milk
- D. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee
Correct Answer: C
Rationale: Meat, dairy products, and dried fruit have high concentrations of potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of high-potassium items.
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.