A nurse is assessing a patient with hypokalemia, she notes that the patient's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?
Assess the patient’s respiratory rate, rhythm, depth
Call the healthcare provider
Document findings and monitor the patient
Measure the patient’s pulse and blood pressure
The Correct Answer is A
A. Assess the patient’s respiratory rate, rhythm, depth:
This is the correct action to take first. Hypokalemia can lead to respiratory muscle weakness, which can result in respiratory compromise or failure. Assessing the patient's respiratory rate, rhythm, and depth will help determine if there are any signs of respiratory distress or impending respiratory failure.
B. Call the healthcare provider:
While it's important to involve the healthcare provider, especially if there is a significant change in the patient's condition, assessing the patient's immediate respiratory status takes priority to ensure prompt intervention if respiratory distress is present.
C. Document findings and monitor the patient:
Documenting findings and ongoing monitoring are essential steps, but they come after addressing the patient's immediate needs, such as assessing respiratory status in this case.
D. Measure the patient’s pulse and blood pressure:
While vital signs are important, they may not immediately address the potential respiratory compromise associated with hypokalemia-induced muscle weakness. Assessing respiratory status is more directly relevant to the observed change in handgrip strength.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. Healthy middle-aged adult who never had chickenpox:
This individual has not had chickenpox, which means they are susceptible to varicella-zoster virus (VZV) infection. If they contract herpes zoster (shingles), they are at risk for complications, although typically healthy adults are less likely to experience severe complications compared to immunocompromised individuals or older adults.
B. Older adult who takes large doses of prednisone for a chronic condition:
Chronic corticosteroid use, such as prednisone, can suppress the immune system and increase the risk of herpes zoster infection. Additionally, if herpes zoster develops in an older adult, they are at higher risk for complications such as postherpetic neuralgia (persistent nerve pain), bacterial superinfection of the rash, and dissemination of the virus.
C. Middle-aged adult who just started taking chemotherapy:
Chemotherapy suppresses the immune system, making individuals more susceptible to infections. If a person undergoing chemotherapy develops herpes zoster, they are at increased risk for serious complications due to their weakened immune response.
D. Nurse who recently received the first dose of varicella vaccine:
The varicella vaccine is designed to prevent chickenpox and reduce the risk of herpes zoster (shingles) in vaccinated individuals. Therefore, a nurse who received the varicella vaccine is less likely to experience serious complications from herpes zoster infection compared to those who are unvaccinated.
E. Young adult who is positive for the human immunodeficiency virus (HIV):
Individuals with HIV have a weakened immune system, increasing their susceptibility to infections, including herpes zoster. Moreover, herpes zoster in HIV-positive individuals can be more severe, prolonged, and may lead to complications such as disseminated herpes zoster, involving multiple organs and potentially becoming life-threatening.
Correct Answer is B
Explanation
A. Infection: While infection can certainly delay wound healing and contribute to the development of chronic wounds, it is more of a local factor rather than a systemic cause. Infections can hinder the normal healing process and lead to tissue damage, inflammation, and prolonged wound healing.
B. Malnutrition
A chronic wound is a wound that fails to progress through the normal stages of healing in an orderly and timely manner. Systemic factors can significantly impact wound healing, and malnutrition is one such systemic cause. Malnutrition, which refers to an inadequate intake or absorption of nutrients essential for healing, can impair the body's ability to repair tissues, fight infection, and generate new cells.
C. Continued pressure: Prolonged pressure, such as that experienced in pressure ulcers, can lead to tissue ischemia (lack of blood flow) and tissue necrosis, resulting in chronic wounds. However, this is considered a local factor related to the specific site of the wound and pressure-related damage.
D. Venous insufficiency: Venous insufficiency can cause chronic wounds, particularly venous ulcers, due to impaired venous return leading to increased pressure in the veins of the lower extremities. This pressure can result in tissue damage and poor wound healing. While venous insufficiency is a systemic condition, it primarily affects specific areas of the body (such as the lower legs) and is more directly related to the development of localized chronic wounds in those areas.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.