A nurse is gathering data from a client who is experiencing hypokalemia due to nausea, vomiting, and diarrhea.
Which of the following symptoms should the nurse anticipate?
Hyperactive reflexes
Extreme thirst
Weak, irregular pulse
Hyperactive bowel sounds
The Correct Answer is C
Choice A rationale
Hyperactive reflexes are not typically associated with hypokalemia. Hypokalemia, or low potassium levels in the blood, can cause muscle weakness, fatigue, constipation, and arrhythmia.
Choice B rationale
Extreme thirst is not a typical symptom of hypokalemia. It is more commonly associated with conditions such as diabetes.
Choice C rationale
A weak, irregular pulse is a common symptom of hypokalemia. Low levels of potassium can affect heart function, leading to abnormal heart rhythms.
Choice D rationale
Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, constipation is a common symptom of this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Hypotension: Frequent vomiting and diarrhea can cause dehydration, which can lead to hypotension.
B. Bradycardia: Bradycardia is not typically a symptom of dehydration caused by vomiting and diarrhea.
C. Pale yellow urine: Dehydration can cause urine to become concentrated, resulting in a darker color, not pale yellow.
D. Poor skin turgor: Dehydration can cause poor skin turgor, which is skin that lacks elasticity.
E. Flat neck veins: Dehydration can cause flat neck veins when the patient is lying supine.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Daily measurement of abdominal girth is crucial in patients with an intestinal obstruction undergoing continuous gastrointestinal decompression. This is because any changes in the abdominal girth can indicate an improvement or worsening of the obstruction. Regular monitoring allows for timely intervention and adjustment of the care plan.
Choice B rationale
Maintaining the patient in Fowler’s position can help promote the drainage of gastric contents via the nasogastric tube. This position, where the patient is seated in bed at an angle of 45-60 degrees, uses gravity to assist in the drainage process, thereby potentially alleviating discomfort and reducing the risk of aspiration.
Choice C rationale
Moistening the patient’s lips with lemon glycerin swabs is not recommended. While it’s important to keep the patient’s lips moist to prevent dryness and cracking due to the nasogastric tube, lemon glycerin swabs can potentially dry out the lips more and cause irritation.
Choice D rationale
Using sterile water to irrigate the nasogastric tube is a standard practice in managing patients with a nasogastric tube. This helps ensure the patency of the tube and prevent blockages, allowing for effective gastrointestinal decompression.
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