Nokea
The nurse is assessing a client's electrocardiogram (ECG) monitoring and notices U-waves. Which electrolyte abnormality may cause this finding?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hypernatremia
- D. Hyponatremia
Correct Answer: B
Rationale: Hypokalemia causes U-waves on ECG due to altered cardiac repolarization.
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The nurse is educating a client about a transurethral resection of the prostate (TURP). Which of the following statements should the nurse make to the client regarding this surgery?
- A. This surgery will remove your entire prostate.
- B. You will have a nasogastric tube (NGT) left in place following this surgery.
- C. You will need to complete a bowel prep the night before this surgery.
- D. A urinary catheter will remain in place following this procedure.
Correct Answer: D
Rationale: A urinary catheter is used post-TURP to manage bleeding and ensure bladder drainage.
The nurse is working with a client who has been diagnosed with hypervolemia. Which of the following conditions can cause hypervolemia? Select all that apply.
- A. Heart failure
- B. Renal failure
- C. Type 1 Diabetes Mellitus
- D. Third degree burns
- E. Hormonal imbalances
Correct Answer: A,B,E
Rationale: Heart failure, renal failure, and hormonal imbalances (e.g., SIADH) impair fluid excretion, causing hypervolemia.
The nurse is caring for a client with a kidney injury with a serum potassium level of 6.1 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. Which of the following actions is a priority?
- A. Obtain a prescription for a diuretic to increase urine output
- B. Check the client's sodium level
- C. Place the client on a cardiac monitor
- D. Encourage oral fluid intake
Correct Answer: C
Rationale: Hyperkalemia (6.1 mEq/L) poses a risk for cardiac dysrhythmias, making cardiac monitoring a priority.
The nurse is caring for a client with peritoneal dialysis. The client reports an outflow of only one-half of the dialysate solution that was dwelled. The nurse should instruct the client to do which of the following?
- A. Apply heat to the abdomen.
- B. Encourage the client to have a bowel movement.
- C. Strip the dialysis catheter.
- D. Instill more dialysate solution.
Correct Answer: B
Rationale: Constipation can obstruct dialysate outflow; encouraging a bowel movement may resolve the issue.
The nurse is caring for a client on a medical floor. The nurse would recognize that which diagnosis increases the client's risk of developing hyperkalemia?
- A. Cushing's syndrome
- B. Acute renal failure
- C. Cystic fibrosis
- D. Bulimia nervosa
Correct Answer: B
Rationale: Acute renal failure impairs potassium excretion, leading to hyperkalemia.