Nokea
A nurse is caring for four clients who have drainage tubes. Which of the following clients is at risk for hypokalemia?
- A. The client who has a tracheostomy tube attached to humidified oxygen.
- B. The client who has an indwelling urinary catheter to gravity drainage.
- C. The client who has a chest tube to water seal.
- D. The client who has a nasogastric tube to suction.
Correct Answer: D
Rationale: The correct answer is D. The client with a nasogastric tube to suction is at risk for hypokalemia because suctioning can lead to loss of gastric contents, which contain potassium. This can result in decreased potassium levels in the body, leading to hypokalemia.
A: The client with a tracheostomy tube attached to humidified oxygen is not at risk for hypokalemia as oxygen therapy does not directly impact potassium levels.
B: The client with an indwelling urinary catheter to gravity drainage is not at risk for hypokalemia as urinary drainage does not affect potassium levels significantly.
C: The client with a chest tube to water seal is not at risk for hypokalemia as chest tube drainage does not lead to potassium loss.
In summary, choice D is correct because suctioning via a nasogastric tube can cause potassium loss, while choices A, B, and C are incorrect as they do not directly impact potassium levels.
You may also like to solve these questions
A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect?
- A. Ulnar deviation
- B. Symmetric joints affected
- C. Pain worsens with activity
- D. Weight loss
Correct Answer: C
Rationale: The correct answer is C: Pain worsens with activity. In osteoarthritis, pain typically worsens with movement or activity due to the degeneration of joint cartilage causing friction between bones. This is a hallmark symptom of osteoarthritis. Ulnar deviation (A) is more commonly seen in rheumatoid arthritis. Symmetric joints affected (B) is also more characteristic of rheumatoid arthritis rather than osteoarthritis. Weight loss (D) is not a typical manifestation of osteoarthritis, unless it is due to decreased physical activity from pain.
A nurse is giving a change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?
- A. Plan of care changes for the upcoming shift
- B. Intracranial pressure readings
- C. Glasgow results
- D. Code status
Correct Answer: D
Rationale: The correct answer is D: Code status. In the background segment of SBAR, the nurse should include the client's code status to ensure the oncoming nurse is aware of the client's wishes in case of a medical emergency. This information is crucial for providing appropriate care and making decisions aligned with the client's preferences. Intracranial pressure readings (B) and Glasgow results (C) are more specific to the current condition of the client and would be included in the assessment segment of SBAR. Plan of care changes for the upcoming shift (A) would be part of the recommendation segment.
A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hours as needed. The amount available is diphenhydramine elixir 12.5 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: Correct Answer: 2 mL
Rationale: To calculate the mL per dose, divide the prescribed mg by the concentration in mg/mL. 25 mg ÷ 12.5 mg/mL = 2 mL. This dosage ensures the correct amount of diphenhydramine is administered.
Summary of Other Choices:
A: Incorrect, as it does not calculate the dosage correctly.
B-G: Irrelevant as they do not provide any calculations or rationale for the correct dosage.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
- A. A negative-pressure isolation room.
- B. A private room.
- C. A semi-private room with a client who has pediculosis capitis.
- D. A positive-pressure isolation room.
Correct Answer: B
Rationale: The correct answer is B: A private room. This is appropriate for a client with scabies to prevent the spread of the infestation to others. A private room allows for isolation and reduces the risk of transmission to other clients.
A: A negative-pressure isolation room is typically used for clients with airborne infections to prevent the spread of pathogens outside the room. Scabies is not transmitted through the air.
C: Placing the client in a semi-private room with a client who has pediculosis capitis (head lice) is not ideal as both conditions are caused by different parasites and may increase the risk of cross-contamination.
D: A positive-pressure isolation room is used for clients who need protection from outside pathogens, not for containing contagious conditions like scabies.
In summary, a private room is the best choice for a client with scabies to prevent transmission to others, while the other options are not appropriate due to the nature of scabies and the need for isolation.
A nurse is teaching a client who has a new prescription for pancrelipase to aid in digestion. The nurse should inform the client to expect which of the following gastrointestinal changes?
- A. Decreased fat in stools
- B. Decreased watery stools
- C. Decreased mucus in stools
- D. Decreased black tarry stools
Correct Answer: A
Rationale: The correct answer is A: Decreased fat in stools. Pancrelipase is a pancreatic enzyme replacement therapy that helps break down fats, proteins, and carbohydrates. Therefore, the client can expect decreased fat in stools as the enzymes aid in the digestion and absorption of fats. Choice B, decreased watery stools, is incorrect as pancrelipase does not directly affect stool consistency. Choices C and D are also incorrect as pancrelipase does not directly impact mucus or the color of stools. Overall, understanding the mechanism of action of pancrelipase helps to determine the correct gastrointestinal change to expect.