Nokea
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.
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The infection control nurse assesses clients at risk for a urinary tract infection (UTI). Which client is at the greatest risk of developing a UTI? A client with
- A. a chronic indwelling urinary catheter receiving intravenous diuretics.
- B. diabetes mellitus who is receiving intravenous antibiotics for a wound infection.
- C. obesity being treated for urge incontinence.
- D. a history of frequent bladder infections.
Correct Answer: A
Rationale: Chronic indwelling catheters significantly increase UTI risk due to prolonged bacterial exposure.
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 reviews a client's laboratory results and notes the potassium level is 5.6 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. Which change to the cardiac rhythm would be expected?
- A. Tall, peaked T waves
- B. ST segment elevation
- C. Peaked P waves
- D. Noticeable U waves
Correct Answer: A
Rationale: Hyperkalemia causes tall, peaked T waves due to altered cardiac repolarization.
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.
The nurse is planning care for a client with a low serum albumin level. Which of the following interventions should the nurse include in the client's plan of care?
- A. Obtain a capillary blood glucose
- B. Implement seizure precautions
- C. Implement strict bed rest
- D. Collaborate with a registered dietician
Correct Answer: D
Rationale: Low albumin requires dietary intervention, best managed with a dietician.