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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Elevating the legs helps to reduce swelling and promotes venous return, which is beneficial for a client with phlebitis. This action improves circulation and aids in preventing the formation of blood clots.
Rolls the extra stocking material down to the client's knee: This action is incorrect because elastic antiembolic stockings should be applied evenly and smoothly without any excess material. Rolling down the extra material can create folds and wrinkles, which can compromise the effectiveness of the stockings and potentially cause discomfort or impaired circulation.
Massages the legs before applying the stockings: Massaging the legs before applying antiembolic stockings is not recommended. Massaging can stimulate blood flow and may dislodge any existing blood clots, posing a risk of embolism. It is important to handle the legs gently and avoid any aggressive or manipulative actions that can disturb the clots.
Positions the client in a chair before applying the stockings: Positioning the client in a chair before applying antiembolic stockings is not the correct action. It is preferable to have the client lie flat in a supine position, with the legs elevated, while applying the stockings. Lying flat helps improve venous return and ensures proper alignment and positioning of the stockings.
Correct Answer is A
Explanation
Answer: (A) Inject 20 units of air into the vial of NPH insulin.
Rationale:
A) Inject 20 units of air into the vial of NPH insulin:
Injecting air into the vial of NPH insulin is the first step to prevent creating a vacuum, which could make it difficult to withdraw the insulin later. The nurse must inject the corresponding amount of air for the dose needed, ensuring that the insulin can be withdrawn smoothly and accurately without bubbles, which could affect the dose.
B) Inject 5 units of air into the vial of regular insulin:
Injecting air into the regular insulin vial is also necessary before withdrawing the insulin, but it should be done after injecting air into the NPH vial. This sequence ensures that no NPH insulin contaminates the regular insulin vial when the nurse withdraws the doses later.
C) Withdraw 20 units of NPH insulin from the vial:
Withdrawing NPH insulin should be done after air is injected into both vials and after the regular insulin has been drawn up. This sequence prevents the mixing of the two types of insulin and ensures accurate dosing, which is crucial for maintaining the correct blood glucose levels.
D) Withdraw 5 units of regular insulin from the vial:
Withdrawing regular insulin is critical to do before the NPH insulin to prevent contamination of the regular insulin with NPH, which could alter the onset and peak times of the regular insulin. However, it should follow the steps of injecting air into both vials, starting with the NPH vial.
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