A nurse is gathering data on a patient who has diarrhea.
Which of the following findings is a sign of hypokalemia?
Hypertension.
Cerebral edema.
Muscle weakness.
Hyperactive bowel sounds.
The Correct Answer is C
Choice A rationale:
Hypertension is not typically a sign of hypokalemia. Hypokalemia, or low potassium levels, can cause symptoms like fatigue, muscle weakness, digestive problems, and frequent urination. Hypertension, or high blood pressure, is not commonly associated with hypokalemia.
Choice B rationale:
Cerebral edema, or swelling in the brain, is not a common symptom of hypokalemia. Hypokalemia is more likely to cause symptoms related to muscle function and digestion, as potassium is an essential mineral that helps regulate muscle contractions, maintain healthy nerve function, and regulate fluid balance.
Choice C rationale:
Muscle weakness is a common symptom of hypokalemia. Potassium helps regulate muscle contractions. When blood potassium levels are low, your muscles produce weaker contractions. This can result in symptoms like muscle weakness and fatigue.
Choice D rationale:
Hyperactive bowel sounds are not typically associated with hypokalemia. Hypokalemia can cause digestive problems, but these are more likely to be issues like constipation rather than increased bowel sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
Donning sterile gloves before inserting the indwelling urinary catheter is a standard practice in healthcare to prevent infection. The urinary tract is normally sterile, and the use of sterile gloves helps maintain this sterility during the catheter insertion process. Choice B rationale:
Oil-based lubricants should not be used with indwelling urinary catheters. These lubricants can damage the catheter material and increase the risk of infection. Instead, water-soluble lubricants are recommended as they do not damage the catheter and can reduce patient discomfort during the insertion process.
Choice C rationale:
Testing the balloon on the indwelling urinary catheter before insertion is a critical step. This is done to ensure that the balloon inflates and deflates properly. If the balloon does not function correctly, it could cause discomfort or injury to the patient during insertion and could fail to keep the catheter in place once inserted.
Choice D rationale:
Cleaning the patient’s urinary meatus with one cotton swab is a part of the standard procedure before inserting an indwelling urinary catheter. This step is taken to remove any bacteria present at the site of insertion, thereby reducing the risk of introducing bacteria into the bladder during the catheter insertion.
Correct Answer is A
Explanation
Choice A rationale:
Urinary retention is a condition where the bladder doesn’t empty all the way or at all when you urinate. This can lead to leakage of urine, as the bladder is overfilled and may result in small amounts of urine escaping. This symptom is often associated with urinary retention and is therefore a likely finding in a client with this condition.
Choice B rationale:
Dark-colored urine is not typically a direct symptom of urinary retention. It can be a sign of dehydration, certain dietary factors, or a side effect of some medications. While it’s possible for a person with urinary retention to have dark-colored urine, it’s not a specific or direct symptom of the condition.
Cloudy urine can be a sign of a urinary tract infection (UTI), which can occur as a complication of urinary retention. However, it’s not a direct symptom of urinary retention itself. A nurse would not necessarily expect to see cloudy urine in a client with urinary retention unless a UTI or another complication was present.
Choice D rationale:
Blood in the urine, or hematuria, is not a typical symptom of urinary retention. It can be a sign of various conditions, including UTIs, kidney stones, or more serious conditions like bladder or kidney disease. While it’s possible for a person with urinary retention to have blood in their urine, it’s not a direct symptom of the condition.
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