A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?
Dyspnea
Oliguria
Pitting edema
Fatigue
The Correct Answer is D
Hypokalemia is a low serum potassium level, usually below 3.5 mEq/L. It can be caused by diuretics that increase potassium excretion, such as thiazides or loop diuretics. Potassium is essential for normal muscle and nerve function, and hypokalemia can impair cardiac, skeletal, and smooth muscle activity. Symptoms of hypokalemia include fatigue, weakness, muscle cramps, arrhythmias, constipation, and hyporeflexia.
- Dyspnea is difficulty or labored breathing that can be caused by various respiratory or cardiac conditions, such as asthma, pneumonia, pulmonary edema, or heart failure. It is not a specific sign of hypokalemia, although severe hypokalemia can affect respiratory muscle function and cause respiratory failure.
- Oliguria is a reduced urine output, usually less than 400 mL per day or 30 mL per hour. It can be caused by various renal or fluid balance disorders, such as acute kidney injury, dehydration, or shock. It is not a specific sign of hypokalemia, although severe hypokalemia can impair renal function and cause renal failure.
- Pitting edema is a swelling of the tissues that leaves an indentation when pressed with a finger. It can be caused by various fluid retention disorders, such as heart failure, liver cirrhosis, or nephrotic syndrome. It is not a specific sign of hypokalemia, although severe hypokalemia can affect fluid and electrolyte balance and cause edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
An exercise stress test is a diagnostic procedure that measures the heart's response to physical activity. The client is instructed to walk on a treadmill or pedal a stationary bike while their heart rate, blood pressure, and electrocardiogram are monitored. The test can help detect coronary artery disease, arrhythmias, or other cardiac problems.
The client should follow certain guidelines before the test, such as:
- Avoiding caffeine, nicotine, alcohol, and stimulants for at least 4 hours before the test, as they can affect the heart rate and blood pressure.
- Fasting for at least 2 hours before the test, as eating can affect the blood flow to the heart.
- Getting adequate rest and sleep the night before the test, as fatigue can affect the performance and results of the test.
- Wearing comfortable clothing and shoes that are suitable for exercise.
- Informing the provider of any medications they are taking, as some medications may need to be withheld or adjusted before the test, such as beta blockers, calcium channel blockers, nitrates, or antiarrhythmics. These medications can affect the heart rate and blood pressure and interfere with the interpretation of the test results.
Therefore, the comment made by the client that indicates a need for further teaching is "I'll take my heart medications the morning of my test." The client should consult with their provider about whether they should take their heart medications or not before the test. The other comments made by the client are appropriate and indicate that they understand the pre-test instructions.
Correct Answer is C
Explanation
Performing neurovascular checks with vital signs is an important action to take following a cardiac catheterization accessed through the femoral artery, as it can help monitor for complications such as bleeding, hematoma, infection, thrombosis, or embolism. The nurse should assess the color, temperature, sensation, movement, and pulses of the affected leg, as well as the blood pressure, heart rate, and oxygen saturation of the client.
Instructing the client to perform range-of-motion exercises to his lower extremities is not appropriate, as it can increase the risk of bleeding or dislodging the arterial sheath or closure device. The client should keep the affected leg straight and avoid bending or lifting it for several hours after the procedure, or as directed by the provider.
Restricting the client's fluid intake is not necessary, as fluid intake can help prevent dehydration and contrast- induced nephropathy following a cardiac catheterization. The client should be encouraged to drink fluids, unless contraindicated.
dAmbulating the client 1 hr following the procedure is not advisable, as it can cause bleeding, hematoma, or vascular injury. The client should remain on bed rest for 2 to 6 hours after the procedure, or as directed by the provider, and resume ambulation gradually and with assistance.
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