A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan?

Give a dose of alendronate.

Administer furosemide.

Apply a cardiac monitor.

Monitor for Chvostek's sign.

Answer and Explanation

The Correct Answer is C

A. Give a dose of alendronate is incorrect. Alendronate is a medication used to treat osteoporosis, and it does not address low potassium levels. In this case, the focus should be on correcting the potassium imbalance.

B. Administer furosemide is incorrect. Furosemide is a diuretic that can cause further loss of potassium. In a client with low potassium levels (hypokalemia., administering furosemide could worsen the condition and lead to life-threatening complications.

C. Apply a cardiac monitor is correct. Hypokalemia (potassium level of 2.9 mEq/L) can cause significant cardiac arrhythmias, including ventricular tachycardia or fibrillation. Applying a cardiac monitor is essential for monitoring the client’s heart rhythm and detecting any abnormalities related to the low potassium level.

D. Monitor for Chvostek's sign is incorrect. Chvostek's sign is indicative of hypocalcemia, not hypokalemia. While both hypocalcemia and hypokalemia can cause neuromuscular excitability, monitoring for Chvostek’s sign is not a priority in the management of hypokalemia.

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Correct Answer is ["A","D","E"]

Explanation

A. Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage.

B. Decreased skin turgor is incorrect. Skin turgor is an indicator of hydration status and is not directly related to compartment syndrome.

C. Pain relieved by analgesia is incorrect. One of the hallmark signs of compartment syndrome is severe pain that is not relieved by analgesia and worsens with passive movement.

D. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment.

E. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle damage.

A. Heart rhythm B. Urinary output C. Pain sensation D. Muscle strength

Correct Answer is A

Explanation

A. Heart rhythm: This is correct. Hypothermia, indicated by a body temperature of 32.5°C (90.5°F), can affect the cardiovascular system, potentially causing arrhythmias or even cardiac arrest. Monitoring heart rhythm is critical because of the risk of life-threatening cardiac complications associated with severe hypothermia.

B. Urinary output: While urinary output may decrease in hypothermic conditions due to vasoconstriction, it is not the priority. Cardiac function takes precedence, as severe hypothermia can lead to fatal arrhythmias.

C. Pain sensation: Although decreased pain sensation can occur in hypothermia, it is less urgent to monitor compared to the potential for life-threatening arrhythmias or cardiac arrest.

D. Muscle strength: While hypothermia can impair muscle strength, it is not the priority compared to monitoring for cardiac irregularities, which can be fatal if left unchecked.

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A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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