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 D
Explanation
Choice A rationale:
Stripping the client’s chest tube every 2 hours is not recommended. Stripping can create high negative pressures in the tube that can cause damage to the lung tissue. It can also lead to increased pain for the patient and is generally not a standard practice in chest tube management.
Choice B rationale:
Looping the tubing of the chest tube on the client’s bed is not a recommended practice. The chest tube should be free of loops or kinks to allow for proper drainage of air and fluid from the pleural space. Any loops or kinks in the tube can lead to accumulation of fluid or air, which can cause complications such as tension pneumothorax.
The chest tube drainage system should not be placed above the level of the client’s heart. This can lead to the backflow of blood or fluid into the pleural space, which can cause complications such as hemothorax or pleural effusion. The drainage system should always be kept below the level of the client’s chest to allow for gravity-assisted drainage.
Choice D rationale:
Taping the connections on the client’s chest tube is a recommended practice. This is done to secure the connections and prevent accidental disconnection or dislodgement of the tube. An accidental disconnection or dislodgement can lead to complications such as pneumothorax or hemothorax. Therefore, all connections should be securely taped to prevent any accidental disconnections.
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Crackles are a common symptom of pleural effusion. They are abnormal lung sounds that are heard when a patient with pleural effusion breathes in. The sound is caused by the opening of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration.
Choice B rationale:
Crepitus is not typically associated with pleural effusion. Crepitus is a crackling or grating sound or feeling produced by air in subcutaneous tissue or by the rubbing together of fragments of broken bone. In the context of respiratory health, crepitus might be felt if there is subcutaneous emphysema, where air gets into tissues under the skin covering the chest wall or neck.
Choice C rationale:
Substernal retractions are not a typical symptom of pleural effusion. Retractions are a sign of respiratory distress, but they are more commonly associated with conditions that cause upper airway obstruction or severe lung disease, such as asthma or pneumonia. Choice D rationale:
Dullness upon percussion is a classic sign of pleural effusion. When there is fluid in the pleural space, it prevents the normal resonant sound produced by the air-filled lungs from being heard. Instead, a dull sound is heard when the chest is percussed.
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