A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

(Select All that Apply.)

Bradycardia

Pale Yellow Urine

Poor Skin Turgor

Hypotension

Flat Neck Veins

Answer and Explanation

Correct Answer : C,D,E

A. Bradycardia: Vomiting and diarrhea usually lead to tachycardia (increased heart rate) as the body compensates for hypovolemia, not bradycardia (slow heart rate).

B. Pale Yellow Urine: Dehydration often causes the urine to become concentrated and dark yellow, not pale yellow.

C. Poor Skin Turgor: Poor skin turgor is a classic sign of dehydration caused by fluid loss.

D. Hypotension: Loss of fluid volume can result in hypotension due to reduced blood circulation.

E. Flat Neck Veins: Dehydration causes reduced venous return, leading to flat neck veins, particularly when lying down.

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Correct Answer is C

Explanation

A. Lactulose: Lactulose is used to treat hepatic encephalopathy by reducing ammonia levels, not for hyperkalemia.

B. Acetylcysteine: Acetylcysteine is used for acetaminophen overdose or as a mucolytic agent, not for hyperkalemia.

C. Sodium polystyrene (Kayexalate): Kayexalate is used to treat hyperkalemia by exchanging sodium for potassium in the intestines, promoting the elimination of potassium through the stool. This is the correct treatment for a potassium level of 6.8 mEq/L, which is dangerously high.

D. Triamterene: Triamterene is a potassium-sparing diuretic and would worsen hyperkalemia, not treat it.

A. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution. B. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution. C. Notify the physician D. Check for kinking of the tubing or a closed clamp.

Correct Answer is D

Explanation

A. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution: This may be necessary later if the occlusion is not resolved by troubleshooting, but the first action should be to check the tubing and clamp for any obstructions.

B. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution: This is not appropriate as an initial action. Heparin flushes are generally used for maintaining patency in central lines and are not indicated for occlusions caused by tubing issues.

C. Notify the physician: While important if the issue persists, this is not the first action. The nurse should attempt to resolve the problem independently first.

D. Check for kinking of the tubing or a closed clamp: This is the first action the nurse should take. Most occlusions are due to kinking in the tubing or a closed clamp, and resolving this issue may immediately restore the flow.

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A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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