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The nurse caring for a client reviews the medical record and determines the client is at risk for developing a potassium deficit because of which situation?

History of Addison's disease.

Has sustained tissue damage.

Uric acid level of 9.4 mg/dL.

Requires nasogastric suction.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. Requires nasogastric suction.

Nasogastric suction removes gastric secretions that contain potassium, leading to a loss of potassium from the body.

This can cause hypokalemia, which is a low level of potassium in the blood.

Choice A is wrong because Addison’s disease causes hyperkalemia, which is a high level of potassium in the blood.

Choice B is wrong because tissue damage can release potassium from the cells into the blood, causing hyperkalemia.

Choice C is wrong because uric acid level is not related to potassium level.

Uric acid is a waste product of purine metabolism that can cause gout or kidney stones if elevated.

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Correct Answer is A

Explanation

The correct answer is choice A, "I will attend a support group to help me handle difficulties when they occur." This statement indicates that the client is accepting the situation and taking proactive steps to manage any difficulties that may arise. Choice B is incorrect because relying on someone else to empty the bag suggests possible denial or avoidance of the situation. Choice C is incorrect because normal bowel movements after an ileostomy may not happen. Choice D is incorrect because it is not related to acceptance of the ileostomy. Choice B is not correct because it shows possible denial or avoidance of the situation. Choice C is not correct because normal bowel movements may not occur. Choice D is not correct because it is not related to acceptance of the ileostomy.

A. Rolls soiled linen with the clean side in before placing it in the laundry bag. B. Cleans a blood spill with chlorine bleach. C. Performs hand hygiene with hands at elbow level. D. Instructs a female client to wipe the perineal area from back to front.

Correct Answer is B

Explanation

The correct answer is choice B, which cleans a blood spill with chlorine bleach. This is an appropriate action for infection control because bleach is an effective disinfectant that can kill most pathogens, including bloodborne viruses such as HIV and hepatitis B and C.

A. Rolling soiled linen with the clean side in it before placing it in the laundry bag is not the correct answer because it can spread pathogens and cause cross-contamination.

Performing hand hygiene with hands at elbow level is not the correct answer because it is not the correct technique for hand hygiene, which involves washing hands with soap and water or using an alcohol-based hand sanitizer.

Instructing a female client to wipe the perineal area from back to front is not the correct answer because it can cause contamination of the urethra and increase the risk of urinary tract infections.

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The nurse caring for a client reviews the medical record and determines the client is at risk for developing a potassium deficit because of which situation?

Nursing Test Bank

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