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 ["A","C","D"]
Explanation
A. Answers questions asked by the nurse: Responding verbally shows the child is engaged and able to understand and participate in the interaction, indicating readiness to cooperate during the assessment.
B. Plays with toys in the examining room: While playing indicates comfort in the environment, it may also reflect distraction or avoidance rather than readiness to cooperate with the nurse’s instructions. Play alone is not a reliable indicator of cooperation.
C. Makes eye contact with the nurse: Eye contact demonstrates attention and willingness to engage with the nurse, which is a positive sign that the child is prepared to follow directions during data collection.
D. Allows the nurse to touch him on the arm: Tolerating touch shows trust and comfort with the nurse’s presence and interventions, signaling the child is ready to participate in the assessment.
E. Sits on his parent's lap when the nurse enters the room: Sitting on a parent’s lap may indicate the child is seeking comfort and security rather than being ready to cooperate independently. This behavior alone does not confirm readiness for assessment.
Correct Answer is C
Explanation
A. Frequent urge to urinate: Urinary frequency and urgency are expected findings after TURP due to bladder and urethral irritation from surgery and catheterization. These sensations typically improve as inflammation subsides and do not require immediate provider notification.
B. Occasional small clots in the urine: Small clots can be expected during the early postoperative period following TURP as the prostatic tissue heals. Continuous bladder irrigation often helps flush these clots, and their presence alone does not indicate a complication unless they become large or obstruct urine flow.
C. Dark red urine: Dark red urine indicates active bleeding and is an abnormal finding 1 day post-TURP. This suggests possible hemorrhage or inadequate hemostasis and requires prompt provider notification to prevent complications such as clot retention or hypovolemia.
D. Urine output of 300 mL over 8 hr: This urine output averages approximately 37.5 mL/hr, which is within acceptable limits for an adult postoperative client. Adequate output suggests sufficient renal perfusion and does not require immediate intervention.
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