A client reports a 2-day history of fever, vomiting, and diarrhea. The healthcare provider prescribes serum electrolyte levels to be obtained.

Reference Range:

Potassium (K+): 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)

Sodium (Na+): 136 to 145 mEq/L (136 to 145 mmol/L)

Which laboratory results should the nurse expect?

Serum potassium: 3.5 mEq/L (3.5 mmol/L), serum sodium: 142 mEq/L (142 mmol/L)

Serum potassium: 4.5 mEq/L (4.5 mmol/L), serum sodium: 140 mEq/L (140 mmol/L)

Serum potassium: 5.0 mEq/L (5.0 mmol/L), serum sodium: 138 mEq/L (138 mmol/L)

Serum potassium: 3.0 mEq/L (3.0 mmol/L), serum sodium: 149 mEq/L (149 mmol/L)

Answer and Explanation

The Correct Answer is D

Choice A rationale: Potassium 3.5 mEq/L and sodium 142 mEq/L are within normal ranges, not expected after vomiting and diarrhea which typically cause hypokalemia and hypernatremia due to fluid loss.

Choice B rationale: Potassium 4.5 mEq/L and sodium 140 mEq/L remain normal, not consistent with dehydration and gastrointestinal fluid loss, which usually lower potassium and elevate sodium concentration.

Choice C rationale: Potassium 5.0 mEq/L and sodium 138 mEq/L are normal values, not typical after prolonged vomiting and diarrhea, where potassium decreases and sodium increases due to water deficit.

Choice D rationale: Potassium 3.0 mEq/L indicates hypokalemia from gastrointestinal losses, and sodium 149 mEq/L indicates hypernatremia from dehydration, both expected findings after vomiting and diarrhea.

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Correct Answer is D

Explanation

Choice A reason: Dizziness is not typically associated with perineal care and is not relevant to the instructions.

Choice B reason: Advising to keep the pubic area shaved is not a standard part of perineal care instructions and is a personal choice.

Choice C reason: The statement about not retracting the foreskin is incorrect; the foreskin should be retracted gently for cleaning and then returned to its normal position to prevent infection.

Choice D reason: It is important to inform the caregiver that an erection may occur as a natural reflex during perineal care, and it does not indicate any sexual intent. This helps prepare the caregiver to handle the situation professionally.

A. "Is there any particular reason why you think this is your fault?" B. "With surgery, your baby should have a full recovery." C. "This must be a very difficult time for you." D. "You did nothing wrong."

Correct Answer is C

Explanation

The correct answer is choice C. “This must be a very difficult time for you.”

Choice A rationale:

Asking the mother why she thinks it is her fault can make her feel defensive and does not provide the emotional support she needs at this moment. It may also imply that there could be a reason for her to feel guilty, which is not helpful.

Choice B rationale:

While it is important to provide hope and information about the prognosis, this response does not address the mother’s immediate emotional distress and feelings of guilt. It focuses on the future rather than acknowledging her current emotional state.

Choice C rationale:

This response is empathetic and acknowledges the mother’s feelings. It provides emotional support and validates her experience, which is crucial in helping her cope with the situation.

Choice D rationale:

Telling the mother she did nothing wrong is important, but it does not fully address her emotional distress. It is a factual statement that may not provide the comfort and understanding she needs at this moment.

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Naxlex Comprehensive Predictor Exams

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

Correct Answer is D

Explanation

The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

Correct Answer is C

Explanation

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (K+) 3.5 to 5 mEq/L (3.5 to 5 mmol/L)

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?

The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?