Nokea
The nurse is reviewing labs for a client with a serum potassium level of 3.3 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. The nurse should take which essential action based on this laboratory result?
- A. Educate the client on potassium-rich foods
- B. Implement continuous telemetry monitoring
- C. Obtain an order for calcium gluconate
- D. Assess the client's neurological status
Correct Answer: A
Rationale: Hypokalemia (low potassium) requires dietary education to increase potassium intake, as it does not typically necessitate telemetry or calcium.
You may also like to solve these questions
Which nursing assessment finding are consistent with hypocalcemia? Select all that apply.
- A. Chvostek's sign
- B. Grey-Turner's sign
- C. Homan's sign
- D. Trousseau's sign
- E. Numbness and tingling of the fingers and toes
Correct Answer: A,D,E
Rationale: Hypocalcemia causes Chvostek's sign, Trousseau's sign, and numbness/tingling due to neuromuscular irritability.
The nurse understands that which of the following are complications of acute tubular necrosis (ATN)? Select all that apply.
- A. Metabolic acidosis
- B. High thyroxine levels
- C. Hyponatremia
- D. Decreased parathyroid levels
- E. Electrolyte imbalances
Correct Answer: A,C,E
Rationale: ATN causes metabolic acidosis, hyponatremia, and electrolyte imbalances due to impaired renal function.
The nurse is reviewing the assignment for the shift and will be caring for the following clients. Which client is at risk for hypokalemia? A client with
- A. hyperemesis gravidarum.
- B. end-stage renal failure.
- C. diabetic ketoacidosis.
- D. third-degree burns.
Correct Answer: A
Rationale: Hyperemesis gravidarum causes potassium loss through vomiting, increasing hypokalemia risk.
The nurse is caring for a client with hyperkalemia. Which of the following treatments would the nurse recognize as appropriate options for treating this electrolyte imbalance? Select all that apply.
- A. Spironolactone
- B. Sodium polystyrene
- C. Regular insulin
- D. Hemodialysis
- E. Magnesium sulfate
Correct Answer: B,C,D
Rationale: Sodium polystyrene (B) binds potassium in the gut, regular insulin (C) shifts potassium into cells, and hemodialysis (D) removes potassium from the blood, all effective for hyperkalemia. Spironolactone (A) is a potassium-sparing diuretic and would worsen hyperkalemia. Magnesium sulfate (E) is not used for hyperkalemia.
The nurse is assessing a client who was just diagnosed with acute pyelonephritis. Which of the following findings should the nurse expect to observe? Select all that apply.
- A. Costovertebral angle tenderness
- B. Jugular venous distention
- C. Fever and chills
- D. Urinary retention
- E. Dysuria
Correct Answer: A,C,E
Rationale: Pyelonephritis causes costovertebral angle tenderness, fever, chills, and dysuria due to kidney inflammation and infection.