A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

The client who has a chest tube to water seal

The client who has a tracheostomy tube attached to humidified oxygen

The client who has an indwelling urinary catheter to gravity drainage

The client who has a nasogastric (NG) tube to suction

Answer and Explanation

The Correct Answer is D

A. A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.

B. A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.

C. An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.

D. A client with an NG tube to suction may experience loss of gastric contents, which can lead to the loss of electrolytes, including potassium. This places the client at risk for hypokalemia.

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Correct Answer is D

Explanation

A) The dorsal surface of the foot is not the most reliable site to assess for cyanosis in individuals with dark skin because the skin pigmentation can mask the bluish tint that indicates reduced oxygenation.
B) Similarly, the dorsal surface of the hand may not clearly show cyanosis due to the thickness and pigmentation of the skin, which can obscure the color change.
C) The pinnae of the ears may also not be the best indicator of cyanosis in dark-skinned individuals because peripheral areas like the ears can be affected by environmental temperatures, leading to misleading color changes.
D) The conjunctivae, however, are a mucous membrane where the skin pigmentation does not affect visibility. Therefore, it is an appropriate site for assessing cyanosis as it allows for the observation of subtle changes in color that indicate hypoxia. This is why the conjunctivae are the correct site to examine for cyanosis in a client with dark skin.

A. Elevate the head of the bed no more than 45°. B. Use a transfer device to lift the client up in bed. C. Massage the skin over the client's bony prominences. D. Apply cornstarch to keep sensitive skin areas dry.

Correct Answer is B

Explanation

A. The head of the bed should generally be elevated no more than 30° to reduce shear and friction, not 45°.
B. Using a transfer device to lift the client prevents shearing and friction, which helps maintain skin integrity and reduces the risk of pressure ulcers.
C. Massaging bony prominences is not recommended, as it can damage underlying tissue and increase risk of ulcer formation.
D. Cornstarch is not advised because it can create a moist environment that promotes skin breakdown and infection.

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A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is D

Explanation

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is B

Explanation

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