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 A
Explanation
A. Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
This response is the best choice because it educates the client about the potential for deeper tissue damage associated with electrical burns. It acknowledges that while the burn on the skin may appear small, the damage underneath could be more extensive, affecting muscles, nerves, and blood vessels.
B. Electrical burns commonly cause reddened/purplish skin without blistering.
This statement is not the best response because it focuses solely on the appearance of the skin without addressing the potential for deeper tissue damage. While it is true that electrical burns can present with reddened or purplish skin without blistering, this response does not provide comprehensive information about the nature and severity of electrical burns.
C. Electrical burns typically are minor.
This response is incorrect because it downplays the seriousness of electrical burns. While some electrical burns may indeed be minor, others can cause significant tissue damage and complications. It's important for the nurse to educate the client about the range of severity that electrical burns can present.
D. Electrical burns usually cause much more skin damage than what can be seen on your skin.
This statement is partially accurate but does not provide as much information as choice A. While it acknowledges that electrical burns can cause more damage than what is visible on the skin's surface, it doesn't emphasize the potential for deeper tissue damage as effectively as choice A does.
Correct Answer is B
Explanation
A. Loose connective tissue:
Melanocytes are not typically found in loose connective tissue. Their primary location is within the epidermis, specifically in the basal layer, where they interact with keratinocytes to produce melanin and contribute to skin color. Loose connective tissue contains collagen and elastin fibers, as well as fibroblasts, but it does not house melanocytes.
B. Epidermis:
This is the correct answer. Melanocytes are primarily located in the basal layer of the epidermis, which is the deepest layer of the epidermis. These cells produce melanin, a pigment that helps protect the skin from UV radiation and determines skin color. Melanocytes are interspersed among keratinocytes in the epidermis and transfer melanin to keratinocytes to provide skin pigmentation.
C. Dermis:
The dermis is the layer of skin beneath the epidermis and consists of connective tissue, blood vessels, nerves, hair follicles, and sweat glands. While the dermis plays a crucial role in supporting and nourishing the epidermis, melanocytes are not primarily located in the dermis. They are confined to the basal layer of the epidermis.
D. Superficial fascia:
The superficial fascia, also known as the subcutaneous tissue or hypodermis, lies beneath the dermis and consists of adipose (fat) tissue and connective tissue. It provides insulation, energy storage, and cushioning for underlying structures. However, melanocytes are not typically found in the superficial fascia. They are restricted to the epidermis, specifically the basal layer, where they carry out their function of melanin production.
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