Nokea
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.
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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 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.
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
- A. Ask family members to speak quietly to keep the client calm
- B. Assess the client's mental status daily
- C. Encourage the client to drink at least 1 liter of fluids each shift
- D. Dangle the client on the bedside before ambulating
Correct Answer: D
Rationale: An older adult with moderate dehydration may experience orthostatic hypotension. Dangling on the bedside before ambulating helps prevent falls and injuries due to sudden blood pressure drops.
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 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.