A nurse notes that a client's serum potassium level is 6 mEq/L. The nurse interprets this as an expected finding in the client with which health problem?

Cushing's

Diabetes insipidus

Addison's

Diarrhea

Answer and Explanation

The Correct Answer is C

Choice A Reason: Cushing's is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excess cortisol and aldosterone production.

Choice B Reason: Diabetes insipidus is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive water loss and dilution of blood.

Choice C Reason: Addison's is an expected health problem in a client with high potassium level, as it causes high potassium level due to insufficient cortisol and aldosterone production.

Choice D Reason: Diarrhea is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive fluid and electrolyte loss.

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Correct Answer is C

Explanation

Choice A Reason: Applying a transparent dressing to the drain site is not an appropriate action for the nurse to take, as it may trap moisture and bacteria and increase infection risk.

Choice B Reason: Clamping the tubing when the client ambulates is not an appropriate action for the nurse to take, as it may cause bile accumulation and leakage and increase pressure and pain.

Choice C Reason: Placing the client into Fowler's position is an appropriate action for the nurse to take, as it helps to promote drainage and prevent reflux of bile into the liver.

Choice D Reason: Securing the tubing to the client's gown is not an appropriate action for the nurse to take, as it may cause tension and displacement of the drain and increase discomfort and bleeding.

A. Compress the nares. B. Administer decongestant for postnasal drip. C. Tilt the head back. D. Collect the drainage.

Correct Answer is D

Explanation

Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.

Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.

Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.

Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.

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A nurse notes that a client's serum potassium level is 6 mEq/L. The nurse interprets this as an expected finding in the client with which health problem?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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