A nurse is collecting data from a client who is receiving IV fluid replacement to treat diarrhea but now has oliguria. Laboratory results include a potassium level of 5.6 mEq/L. The nurse should report which of the following findings to the provider immediately?
Muscle weakness
Paresthesias
Abdominal cramps
Palpitations
The Correct Answer is D
Choice A Reason:
Muscle weakness is incorrect. Muscle weakness can be a symptom of hyperkalemia (elevated potassium levels). However, it is not the most urgent symptom, and the provider should be informed to address the underlying cause.
Choice B Reason:
Paresthesias is incorrect. Paresthesias (tingling or numbness) can also occur with hyperkalemia. While important to assess, it may not be the most urgent symptom requiring immediate attention.
Choice C Reason:
Abdominal cramps is incorrect. Abdominal cramps can be associated with hyperkalemia, but they are not the most critical symptom. It's essential to address the underlying cause, but it may not require immediate intervention compared to other symptoms.
Choice D Reason:
Palpitations is correct. Palpitations are a concerning symptom, especially in the context of hyperkalemia. Elevated potassium levels can lead to cardiac arrhythmias, and palpitations may be indicative of serious cardiac complications. This is a critical finding that requires immediate attention from the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Adding diluent to the medication is not appropriate for ampules. Ampules typically contain a single-dose of medication in a liquid form.
Choice B Reason:
The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.
Choice C Reason:
A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.
Choice D Reason:
Injecting air into the ampule is not necessary. Ampules are designed to allow for the withdrawal of medication without the need to inject air.
Correct Answer is C
Explanation
A. A family member is napping in the client's room.
This situation, while not ideal, doesn't involve harm or potential harm to a client, staff, or visitor. It may be addressed through communication and policy reminders but may not require an incident report.
B. A client refuses to eat at mealtime.
Client refusal to eat, while concerning, is not an unexpected or unusual event. It is a common aspect of care, and incident reports are not typically used for such situations.
C. A client's bed alarm is malfunctioning.
This situation involves a malfunction in equipment designed to ensure client safety. It has the potential to compromise the safety of the client and may require an incident report to document the issue and address it appropriately.
D. An assistive personnel is late for the upcoming shift.
Lateness may be an issue that needs addressing, but it's not typically considered an incident requiring a formal incident report. This situation may be addressed through workplace policies and communication.
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