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:
Turning the hearing aid off for 5 minutes is inappropriate action. Turning the hearing aid off may temporarily stop the whistling sound, but it doesn't address the underlying issue. Additionally, it would leave the client without the ability to hear during that time.
Choice B Reason:
Cleaning the hearing aid with isopropyl alcohol is inappropriate action. While cleaning the hearing aid is important for maintenance, using isopropyl alcohol may not directly address the issue of whistling. It's a good practice for routine cleaning, but it may not be the solution in this specific case.
Choice C Reason:
Decreasing the volume on the hearing aid is appropriate action. Whistling sounds, also known as feedback, can occur when the volume on the hearing aid is too high. Decreasing the volume is a reasonable first step to address this issue.
Choice D Reason:
Soaking the hearing aid in warm water is inappropriate. Soaking a hearing aid in warm water is not recommended, as moisture can damage the internal components of the hearing aid. It's essential to keep hearing aids dry to ensure proper functioning.
Correct Answer is D
Explanation
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.
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