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 D
Explanation
Choice A rationale
Broth is a clear liquid that can help replace sodium and chloride lost through diarrhea. However, it does not contain the necessary amounts of other electrolytes such as potassium and bicarbonate, which are also commonly lost in diarrhea.
Choice B rationale
Apple juice is not a good choice for a child with acute diarrhea. It is high in sugars and can worsen diarrhea. It also does not contain the electrolytes needed to replace those lost through diarrhea.
Choice C rationale
Cherry gelatin is not a suitable choice. While it is a clear liquid that can help with hydration, it does not contain the necessary electrolytes to replace those lost through diarrhea. It is also high in sugars, which can worsen diarrhea.
Choice D rationale
Pedialyte is the best choice for a child with acute diarrhea who reports that he is thirsty. It is a rehydration solution specifically designed to replace fluids and electrolytes lost through diarrhea.
Correct Answer is D
Explanation
Choice A rationale
Requesting the providers to initiate antibiotic therapy for every patient on the unit is not the most appropriate action. Antibiotics should only be used when there is a confirmed bacterial infection. Overuse of antibiotics can lead to antibiotic resistance and can potentially trigger C. difficile infection due to disruption of normal gut flora.
Choice B rationale
While performing hand hygiene with an alcohol-based agent is important in general infection control, it is not the most effective measure against C. difficile.
C. difficile spores are resistant to destruction by alcohol-based hand rubs. Therefore, hand hygiene for C. difficile should involve washing with soap and water.
Choice C rationale
Obtaining stool cultures from all patients on the nursing unit is not the most appropriate action. Stool cultures should be obtained from patients who are symptomatic. Testing asymptomatic patients can lead to false positives and unnecessary treatment.
Choice D rationale
Placing all patients who have symptoms on contact precautions is the correct answer. Contact precautions, including the use of gloves and gowns, can prevent the spread of C. difficile. This is because C. difficile is spread via the fecal-oral route, and its spores can survive on surfaces for long periods.
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