A nurse is assessing a client who has hypokalemia. Which of the following findings should the nurse expect?

Strong, bounding pulse

Positive Chvostek's sign

Hyperactive reflexes

Decreased bowel sounds

Answer and Explanation

The Correct Answer is D

A. Strong, bounding pulse: Hypokalemia causes weak, thready, or irregular pulses due to its effects on cardiac muscle excitability. A strong, bounding pulse is more characteristic of hypervolemia or other cardiovascular conditions.

B. Positive Chvostek's sign: A positive Chvostek’s sign is associated with hypocalcemia, not hypokalemia. It indicates neuromuscular excitability due to low calcium levels.

C. Hyperactive reflexes: Hypokalemia generally causes muscle weakness, fatigue, and diminished or hypoactive reflexes rather than hyperactive reflexes.

D. Decreased bowel sounds: Low potassium levels reduce smooth muscle excitability in the gastrointestinal tract, leading to decreased peristalsis and hypoactive bowel sounds, which is a common finding in hypokalemia.

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Correct Answer is A

Explanation

A. 65 mL: The total liquid intake includes 30 mL of water used to flush the NG tube before the medication, 5 mL of medication instilled, and 30 mL of water used to flush the tube afterward. Adding these together gives 65 mL, which accurately reflects all fluids administered.

B. 5 mL: Documenting only the medication omits the water used for flushing, underrepresenting the client’s total fluid intake.

C. 35 mL: This amount accounts only for the post-flush water and medication, it ignores the pre-flush water, resulting in an inaccurate intake record.

D. 60 mL: This underestimates the total intake by failing to include all three components correctly; precise documentation is essential for fluid balance monitoring.

A. Provide the client with an alcohol-based mouthwash. B. Instruct the client to brush their remaining teeth with a firm toothbrush. C. Advise the client to rinse their mouth and dentures after each meal. D. Swab the client's mouth with lemon-glycerin sponges at bedtime.

Correct Answer is C

Explanation

A. Provide the client with an alcohol-based mouthwash: Alcohol-based mouthwashes can cause oral mucosa dryness and irritation, worsening mouth pain. They are not recommended for clients with oral discomfort or partial dentures.

B. Instruct the client to brush their remaining teeth with a firm toothbrush: A firm toothbrush can damage gum tissue and increase discomfort, especially in a client already experiencing pain. A soft-bristled toothbrush is safer for maintaining oral hygiene without causing trauma.

C. Advise the client to rinse their mouth and dentures after each meal: Rinsing after meals removes food particles and prevents bacterial buildup, reducing irritation and risk of infection. This promotse oral health and comfort in clients with partial dentures.

D. Swab the client's mouth with lemon-glycerin sponges at bedtime: Lemon-glycerin swabs can dry out the mucous membranes and cause irritation. They are no longer recommended in oral care because they worsen discomfort rather than relieve it.

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A nurse is assessing a client who has hypokalemia. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has administered 5 mL of medication to a client via NG tube. They used 30 mL of water to flush the tube both before and after the instillation. The nurse should document which of the following amounts as liquid intake for the client?

Correct Answer is A

Explanation

A nurse is assessing a client who wears partial dentures and reports mouth pain. Which of the following actions should the nurse take?

Correct Answer is C

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