Nokea
The nurse monitors a client prescribed a thiazide diuretic for which clinical manifestations of hypokalemia? Select all that apply.
- A. Muscle twitches
- B. Deep tendon hyporeflexia
- C. Prominent U wave on ECG
- D. General skeletal muscle weakness
- E. Hypoactive to absent bowel sounds
- F. Tall T waves on electrocardiogram (ECG)
Correct Answer: B,C,D,E
Rationale: Hypokalemia is a serum potassium level less than 3.5 mEq/L. Clinical manifestations include ECG abnormalities such as ST depression, inverted T wave, prominent U wave, and heart block. Other manifestations include deep tendon hyporeflexia, general skeletal muscle weakness, decreased bowel motility and hypoactive to absent bowel sounds, shallow ineffective respirations and diminished breath sounds, polyuria, decreased ability to concentrate urine, and decreased urine specific gravity. Tall T waves and muscle twitches are manifestations of hyperkalemia.
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The nurse is monitoring a client in the telemetry unit who has recently been admitted with the diagnosis of chest pain and notes this heart rate pattern on the monitoring strip. What is the initial action to be taken by the nurse?
- A. Notify the primary health care provider.
- B. Initiate cardiopulmonary resuscitation (CPR).
- C. Continue to monitor the client and the heart rate patterns.
- D. Administer oxygen with a face mask at 8 to 10 L per minute.
Correct Answer: B
Rationale: The monitor is showing ventricular fibrillation, a life-threatening dysrhythmia that requires CPR and defibrillation to maintain life. Although the primary health care provider must be notified, CPR is the initial action. Oxygen is necessary, but again the initiation of CPR is the priority because it will provide more than just oxygen to the client. Monitoring the client is necessary, but not as an initial action; emergency resuscitative treatment must be provided to the client immediately.
The nurse is caring for a client receiving bolus feedings via a nasogastric (NG) tube. The nurse should place the client in which position to administer the feeding?
- A. Supine
- B. Semi-Fowler's
- C. Trendelenburg's
- D. Lateral recumbent
Correct Answer: B
Rationale: Clients are at high risk for aspiration during an NG tube feeding because the tube bypasses a protective mechanism, the gag reflex. The head of the bed is elevated 35 to 40 degrees (Semi-Fowler's) to prevent this complication by facilitating gastric emptying. The remaining options increase the risk of aspiration by blunting the effect of gravity on gastric emptying.
The client diagnosed with chronic kidney disease is scheduled for hemodialysis. When should the nurse plan to administer the client's daily dose of enalapril to ensure its effectiveness?
- A. During dialysis
- B. Just before dialysis
- C. The day after dialysis
- D. Upon return from dialysis
Correct Answer: D
Rationale: Antihypertensive medications, such as enalapril, are administered to the client after hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. There is no rationale for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure.
A client with a spinal cord injury is at risk of developing footdrop. What intervention should the nurse use as a preventive measure?
- A. Mole skin-lined heel protectors
- B. Regular use of posterior splints
- C. Application of pneumatic boots
- D. Avoiding dorsal flexion of the foot
Correct Answer: B
Rationale: The effective means of preventing footdrop (plantar flexion) is the use of posterior splints or high-top sneakers. Dorsal flexing of the foot would help to counteract the effects of footdrop. Heel protectors protect the skin but do not prevent footdrop. Pneumatic boots prevent deep vein thrombosis but not footdrop.
A client admitted to the hospital with a diagnosis of cirrhosis demonstrates massive ascites causing dyspnea. The nurse performs which intervention as a priority measure to assist the client with this complication?
- A. Repositions side to side every 2 hours
- B. Elevates the head of the bed 60 degrees
- C. Auscultates the lung fields every 4 hours
- D. Encourages deep breathing exercises every 2 hours
Correct Answer: B
Rationale: The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid in the abdomen. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures in the care of a client with ascites, but the priority measure is the one that relieves diaphragmatic pressure thus assisting effective respirations.