A nurse is admitting a client who reports excessive thirst, fever, and periods of confusion. The nurse suspects the client is experiencing heat exhaustion. Which of the following electrolyte imbalances should the nurse expect?

Hypernatremia

Hypocalcemia

Hyperkalemia

Hyperphosphatemia

Answer and Explanation

The Correct Answer is A

A. Hypernatremia: Excessive fluid loss through sweat, combined with insufficient fluid intake, can lead to hypernatremia (elevated sodium levels), often seen in heat exhaustion.
B. Hypocalcemia: Calcium levels are not typically affected by heat exhaustion.
C. Hyperkalemia: Potassium levels usually decrease due to sweating, not increase.
D. Hyperphosphatemia: Phosphate levels are not significantly altered in heat exhaustion.

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Correct Answer is D

Explanation

A. "There is no cure for MRSA.": MRSA infections can be treated with specific antibiotics.
B. "We will need to wear masks when we are in the hospital room.": Masks are not necessary for contact precautions unless there is an additional indication, such as droplet precautions.
C. "MRSA only occurs in health care facilities.": MRSA can occur in both community and healthcare settings.
D. "We should remove gloves before leaving the hospital room.": Gloves and gowns must be removed inside the room to prevent contamination of the hospital environment.

A. Empty the pouch when it is 1/3 to 1/2 full. B. Use a standard enema set to irrigate the colostomy. C. Cleanse the skin surrounding the stoma with moisturizing soap. D. Cut the opening in the skin barrier 1/4 inch larger than the stoma.

Correct Answer is A

Explanation

A. Empty the pouch when it is 1/3 to 1/2 full: This prevents the weight of the pouch from causing leaks or pulling on the stoma.
B. Use a standard enema set to irrigate the colostomy: This is incorrect as a standard enema set is not typically used. Colostomy irrigation requires specific equipment and is not performed routinely.
C. Cleanse the skin surrounding the stoma with moisturizing soap: Moisturizing soap can leave a residue that interferes with adhesive barriers. Mild, non-moisturizing soap or just water should be used.
D. Cut the opening in the skin barrier 1/4 inch larger than the stoma: The opening should fit closely to the stoma to protect the surrounding skin from irritation and leakage.

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A nurse is admitting a client who reports excessive thirst, fever, and periods of confusion. The nurse suspects the client is experiencing heat exhaustion. Which of the following electrolyte imbalances should the nurse expect?

Nursing Test Bank

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