Nokea
The nurse cares for a client with a potassium of 5.7 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. The nurse understands that this potassium level may be caused by Select all that apply.
- A. Cushing's disease.
- B. nasogastric tube suctioning.
- C. salt substitutes.
- D. hyperinsulinism.
- E. adrenal insufficiency.
Correct Answer: C,E
Rationale: Salt substitutes (potassium-based) and adrenal insufficiency (reduced aldosterone) cause hyperkalemia.
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Following surgery for a prolapsed bladder, a 74-year-old female client is two days postoperative with an indwelling urinary catheter. While the nurse is making morning rounds, the client states, 'I feel like peeing again!' The most appropriate response for the nurse is:
- A. It's just bladder spasms. Nothing to worry about.'
- B. Let me look at your urine bag to ensure it's draining properly.'
- C. You should do Kegel exercises regularly to stop this urge to void.'
- D. Is this the first time this has happened?'
Correct Answer: B
Rationale: Checking the urine bag ensures the catheter is draining properly, addressing the sensation of needing to urinate.
The nurse is assessing a client who was admitted four hours ago with hypomagnesemia. Which of the following findings should the nurse recognize as a common cause of hypomagnesemia? Select all that apply.
- A. Renal failure
- B. Alcoholism
- C. Anorexia nervosa
- D. Diarrhea
- E. Hypothyroidism
Correct Answer: B,C,D
Rationale: Alcoholism, anorexia nervosa, and diarrhea cause magnesium loss through malnutrition, malabsorption, or gastrointestinal losses.
When assessing for dehydration, the nurse should observe for which of the following?
- A. Headache and increased urinary output
- B. Weight gain and edema
- C. Hypertension and decreased urinary output
- D. Hypotension, headache, and dry mucous membranes
Correct Answer: D
Rationale: Dehydration causes hypotension, headache, and dry mucous membranes due to fluid loss.
The nurse cares for a client with a potassium of 3.2 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. Which of the following medications may cause this abnormality?
- A. spironolactone
- B. triamterene
- C. prednisone
- D. lisinopril
Correct Answer: B
Rationale: Triamterene is a potassium-sparing diuretic that can cause hypokalemia by reducing potassium excretion. Spironolactone (A) also spares potassium but is less likely to cause hypokalemia. Prednisone (C) primarily affects glucose and sodium, not potassium. Lisinopril (D) may cause hyperkalemia, not hypokalemia.
The nurse is teaching a client about consuming cranberry juice to prevent recurrent simple cystitis. The nurse understands that the treatment goal of consuming cranberry is to
- A. increase the urine specific gravity.
- B. increase the urine leukocyte count.
- C. acidify the urine.
- D. increase the protein in the urine.
Correct Answer: C
Rationale: Cranberry juice acidifies urine, creating an unfavorable environment for bacterial growth, helping prevent cystitis.