Nokea
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.
You may also like to solve these questions
A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first?
- A. Prepare to administer sodium polystyrene sulfonate (Kayexalate) 15 g by mouth
- B. Provide a client healthy, low potassium diet
- C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push
- D. Prepare the client for hemodialysis treatment
Correct Answer: C
Rationale: A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the serum potassium level. Insulin with dextrose enhances potassium movement into cells, reducing serum levels quickly. This is the fastest and most immediate intervention.
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 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.
A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
- A. Measure the client's pulse and blood pressure
- B. A 5-year-old who is cognitively impaired
- C. Applying oxygen by mask or nasal cannula
- D. Increase oral fluid intake
Correct Answer: D
Rationale: For a client with dehydration-induced confusion, the priority is to address the dehydration by increasing fluid intake to restore hydration status, which may help resolve confusion. Measuring vital signs, assessing cognitive status, or applying oxygen may be secondary actions but do not directly address the underlying cause of dehydration.
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.