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 D

Explanation

Moving objects away from the client is an important action to take during a seizure, as it can prevent injury and protect the client from harm.

"Place the client on his back." is not correct, as it can cause 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.

"Restrain the client." 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.

"Insert a padded tongue blade into 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. "Apply ice packs to your legs." B. "Place your legs in a dependent position while in bed." C. "Remain on bed rest." D. "Use elastic stockings."

Correct Answer is D

Explanation

Using elastic stockings is an eﬀective way to improve venous return and prevent edema, stasis, and ulceration in clients who have venous insufficiency. The stockings should be applied before getting out of bed and worn throughout the day.

"Apply ice packs to your legs." is not appropriate, as ice packs can cause vasoconstriction and impair blood ﬂow to the legs, worsening the condition.

"Place your legs in a dependent position while in bed." is not advisable, as dependent position can increase venous pressure and ﬂuid accumulation in the legs, leading to edema, pain, and skin breakdown

"Remain on bed rest." is not necessary, as bed rest can reduce muscle contraction and impair venous return. The client should be encouraged to perform regular exercise, such as walking, to enhance circulation and prevent complications.

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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

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