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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A client hospitalized with a diagnosis of thrombophlebitis is being treated with heparin infusion therapy. About 24 hours after the infusion has begun, the nurse notes that the client's partial thromboplastin time (PTT) is 65 seconds with a control of 30 seconds. What nursing action should the nurse implement?
- A. Discontinue the heparin infusion.
- B. Prepare to administer protamine sulfate.
- C. Notify the primary health care provider of the laboratory results.
- D. Include in report that the client is adequately anticoagulated.
Correct Answer: D
Rationale: The effectiveness of heparin therapy is monitored by the results of the PTT. Desired range for therapeutic anticoagulation is 1.5 to 2.5 times the control. A PTT of 65 seconds is within the therapeutic range. Therefore, options 1, 2, and 3 are incorrect actions.
A client has been diagnosed with left tension pneumothorax. Which finding observed by the nurse indicates that the pneumothorax is rapidly worsening? Select all that apply.
- A. Hypertension
- B. Flat neck veins
- C. Increased cyanosis
- D. Tracheal deviation to the right
- E. Diminished breath sounds on the left
- F. Observable asymmetry of the thorax
Correct Answer: C,D,E,F
Rationale: A tension pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), tracheal deviation to the unaffected side, asymmetry of the thorax, decreased to absent breath sounds on the affected side, worsening cyanosis, and worsening dyspnea. The increased intrathoracic pressure causes the blood pressure to fall, not rise.
A client is receiving cisplatin. On assessment of the client, which findings indicate that the client is experiencing an adverse effect of the medication?
- A. Tinnitus
- B. Increased appetite
- C. Excessive urination
- D. Yellow halos in front of the eyes
Correct Answer: A
Rationale: Cisplatin is an antineoplastic medication. An adverse effect related to the administration of cisplatin is ototoxicity with hearing loss. The nurse should assess for this adverse reaction when administering this medication. Options 2, 3, and 4 are not adverse effects of this medication.
The nurse assists the primary health care provider with the removal of a chest tube. During the procedure, the nurse instructs the client to perform which action?
- A. Inhale deeply.
- B. Breathe normally.
- C. Breathe out forcefully.
- D. Take a deep breath and hold it.
Correct Answer: D
Rationale: The client is instructed to take a deep breath and hold it for chest tube removal. This maneuver will increase intrathoracic pressure, thereby lessening the potential for air to enter the pleural space. Therefore, options 1, 2, and 3 are incorrect.
A visiting home care nurse finds a client unconscious in the bedroom. The client has a history of abusing the selective serotonin reuptake inhibitor, sertraline. The nurse should immediately conduct which assessment?
- A. Pulse
- B. Respirations
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: In an emergency situation, the nurse should determine breathlessness first and then assess for a pulse. Blood pressure would be assessed after these assessments are performed. Urinary output is also important but is not the priority at this time.