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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Advise the client about increased dry mouth. Transdermal clonidine can cause xerostomia, or dry mouth, due to a decrease in salivary secretion. The nurse should advise the client to maintain good oral hygiene and to increase fluid intake to prevent oral and dental problems.
An explanation for incorrect choices:
A. Weight loss is not a common adverse effect or risk associated with transdermal clonidine.
C. Diarrhea can occur with transdermal clonidine, but it is not a common adverse effect or risk.
D. Hypopigmentation is rare with transdermal clonidine; it is more common with corticosteroids.
Correct Answer is C
Explanation
The correct answer is c. Apply a moist saline dressing to the area.
Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.
Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.
Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.
Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.
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