A nurse is collecting data from a client who has hypokalemia and recently started potassium chloride supplements. Which of the following findings indicates a positive response to the intervention?
Reduced anxiety
Normal sinus rhythm
Decreased urinary output
Decreased blood pressure
The Correct Answer is B
A. Reduced anxiety: While anxiety may improve with overall health stabilization, it is not a direct indicator of potassium replacement effectiveness. Potassium primarily affects neuromuscular and cardiac function rather than emotional state.
B. Normal sinus rhythm: Hypokalemia can cause cardiac arrhythmias. The presence of a normal sinus rhythm indicates that potassium levels have been corrected and the heart’s electrical activity is stabilized, reflecting a positive response to supplementation.
C. Decreased urinary output: Changes in urinary output are not a direct measure of potassium replacement effectiveness and may indicate other complications, such as renal impairment or fluid imbalance.
D. Decreased blood pressure: Blood pressure changes are not a direct outcome of potassium supplementation and could suggest unrelated cardiovascular issues. Normalization of cardiac rhythm is a more specific indicator of intervention success.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply friction to hands for 10 seconds: Effective hand hygiene requires rubbing hands together with friction for at least 20 seconds to remove pathogens. Ten seconds is insufficient to ensure proper cleaning and reduce infection risk.
B. Interlace the fingers while rubbing hands together: Interlacing the fingers ensures that all surfaces, including the spaces between fingers, are cleaned thoroughly. This technique helps remove microorganisms from areas often missed during handwashing.
C. Dry hands starting from forearm to fingers: Hands should be dried from fingers to forearm to prevent contamination from runoff water. Drying in the opposite direction can transfer pathogens back onto the hands.
D. Use hot water to wash hands: Hot water is not recommended because it can cause skin irritation and dryness. Warm or lukewarm water is effective for hand hygiene while maintaining skin integrity.
Correct Answer is A
Explanation
A. Observe the client during and after meals: Monitoring the client for bingeing or purging behaviors is the priority intervention because it addresses immediate safety and physical health risks, such as electrolyte imbalances. Direct observation prevents harmful behaviors and allows timely intervention.
B. Refer the client to a support group for clients who have eating disorders: Referral is important for long-term psychosocial support, but it does not address immediate risk or safety concerns during meals.
C. Instruct the client about effective coping strategies: Teaching coping strategies is beneficial for long-term management, but ensuring safety during meals takes precedence in the nursing process.
D. Suggest that the client assist with meal planning: Involving the client in meal planning promotes autonomy and engagement in treatment, but it is not the first action when immediate monitoring is required to prevent harmful behaviors.
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