Nokea
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.
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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 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.
A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?
- A. Client with fever and rapid respirations
- B. Client with diabetes mellitus
- C. Client receiving intravenous isotonic fluids
- D. Client with stable heart failure
Correct Answer: A
Rationale: Insensible water loss occurs through the skin, lungs, and stool. Clients with fever and rapid respirations lose more water through increased respiratory rate and perspiration, putting them at greatest risk for insensible water loss.
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 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.