A nurse in an urgent care clinic is collecting data from a client who reports having diarrhea for the past 3 days. Which of the following findings indicates hypokalemia?
Pitting edema
Diplopia
Muscle weakness
Hyperactive bowel sounds
The Correct Answer is C
A nurse collecting data from a client who reports having diarrhea for the past 3 days should identify that muscle weakness is a symptom of hypokalemia. Hypokalemia is a condition in which the blood potassium level is low and can be caused by excessive fluid loss through diarrhea. Potassium helps regulate muscle contractions, so when blood potassium levels are low, muscles may produce weaker contractions which result in muscle weakness.
The other options are not typical symptoms of hypokalemia.
a) Pitting edema is not a typical symptom of hypokalemia.
b) Diplopia is not a typical symptom of hypokalemia.
d) Hyperactive bowel sounds are not a typical symptom of hypokalemia.
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Related Questions
Correct Answer is D
Explanation
The priority data for the nurse to collect following an amniotomy is the fetal heart rate. This is an important nursing intervention to assess fetal well-being and identify any potential complications.
a) Assessing the color of the amniotic fluid is important, but it is not the highest priority.
b) Monitoring the client's temperature is important, but it is not the highest priority.
c) Assessing the frequency of contractions is important, but it is not the highest priority.
Correct Answer is ["A","B","C"]
Explanation
The correct answers are a. Document urine color, b. Monitor the client for reports of bladder spasms, and
c. Check the drainage tubing for obstructions.
a. Documenting urine color is important to monitor for any changes that may indicate complications or issues with the bladder irrigation. It helps identify any bleeding or clot formation.
b. Monitoring the client for reports of bladder spasms is crucial as bladder spasms can indicate irritation or obstruction in the urinary system. Prompt intervention can be provided to alleviate discomfort and prevent complications.
c. Checking the drainage tubing for obstructions is essential to ensure proper flow of the bladder irrigation solution. Obstructions in the tubing can lead to inadequate irrigation, which can affect the effectiveness of the procedure and potentially lead to complications.
d. Maintaining the client in a left side-lying position is not specifically indicated for continuous bladder irrigation after a transurethral resection of the prostate. The client's position should be based on their comfort and overall condition, and there is no specific requirement for a left side-lying position in this context.
e. Using clean technique for intermitent irrigation is not appropriate for continuous bladder irrigation. Continuous bladder irrigation requires aseptic technique to reduce the risk of infection and contamination.
By performing these actions, the nurse ensures proper monitoring, documentation, and maintenance of the bladder irrigation system, promoting the client's safety and well-being.
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