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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Free Nursing Study Resources

Correct Answer is D

Explanation

This respiratory care scenario requires applying knowledge of oxygen delivery systems and normal physiological responses. To answer correctly, the nurse must understand the mechanical function of a partial rebreather mask and recognize the significance of a normal adult respiratory rate during therapy.

Choice A rationale: Increasing the oxygen liter flow is unnecessary because the reservoir bag is already functioning correctly by not deflating completely. Liter flow for this mask must be high enough (typically 6 to 11 L/min) to keep the bag two-thirds full.

Choice B rationale: Encouraging deep breaths is not indicated as the client's respiratory rate of 14 breaths/minute is within the normal adult range of 12 to 20 breaths/minute. The current breathing pattern is effectively facilitating oxygenation without the need for coaching.

Choice C rationale: Removing the mask would interrupt oxygen therapy and is contraindicated. The reservoir bag is supposed to remain partially inflated during inhalation to ensure the client receives the prescribed oxygen concentration rather than room air or exhaled carbon dioxide.

Choice D rationale: The reservoir bag of a partial rebreather mask should not deflate completely during inspiration to prevent carbon dioxide buildup. Since the bag is functioning normally and the respiratory rate is stable, the nurse should simply document these findings.

A. Shufling gait. B. Urinary incontinence. C. Syncope when bending. D. Hand tremors.

Correct Answer is ["C","D"]

Explanation

Choice A rationale: A shuffling gait increases fall risk but does not directly impair ability to perform foot care or toenail trimming, so UAP assignment is not primarily indicated here.

Choice B rationale: Urinary incontinence affects bladder control, not manual dexterity or safety during foot care. It does not necessitate UAP assistance for toenail trimming or routine foot care.

Choice C rationale: Syncope when bending increases risk of fainting during foot care tasks, making independent toenail trimming unsafe. UAP support ensures safety and prevents injury during routine care.

Choice D rationale: Hand tremors impair fine motor control, making toenail trimming difficult and unsafe. UAP assistance is indicated to prevent injury and ensure proper routine foot care.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Correct Answer is ["C","D"]

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

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

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

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 is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

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?