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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Placing the client on his side is an essential action to take during a seizure, as it can prevent airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.

Holding the client's arms and legs from moving is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.

Placing the client back in bed is not necessary, as it can cause harm or delay care. The client should be left on the ﬂoor, unless it is unsafe or uncomfortable, and padded with pillows or blankets to protect from injury.

Inserting a tongue blade in the client's mouth is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.

A. Closure of pulmonic valve B. Closure of the mitral valve C. Ventricular gallop D. Atrial gallop

Correct Answer is C

Explanation

Ventricular gallop is another name for the S3 sound, which is a low-pitched sound heard at the end of diastole, just after the S2 sound. It is caused by the rapid filling of the ventricles and the vibration of the ventricular walls.

Closure of the pulmonic valve is one of the components of the S2 sound, which is a high-pitched sound heard at the end of the systole, just before the S1 sound. It is caused by the closure of the semilunar valves (pulmonic and aortic).

Closure of the mitral valve is one of the components of the S1 sound, which is a high-pitched sound heard at the beginning of systole, just after the S2 sound. It is caused by the closure of the atrioventricular valves (mitral and tricuspid).

d. Atrial gallop is another name for the S4 sound, which is a low-pitched sound heard at the end of diastole, just before the S1 sound. It is caused by atrial contraction and increased resistance to ventricular filling.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client's room and finds the client on the ﬂoor having a seizure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?

Correct Answer is C

Explanation

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?

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