A patient who is taking a potassium-wasting diuretic for the treatment of hypertension reports generalized weakness. Which action is appropriate for the nurse to take?
Ask the patient about loose stools
Suggest that the healthcare provider order a basic metabolic panel
Assess for facial muscle spasms
Call for a rapid response team
The Correct Answer is B
Choice A reason: Asking the patient about loose stools is important as it can help identify possible causes of fluid and electrolyte imbalances. However, this question alone would not be the immediate or primary action to take in response to generalized weakness.
Choice B reason: Suggesting that the healthcare provider order a basic metabolic panel is the most appropriate action. Potassium-wasting diuretics can lead to hypokalemia, which can cause symptoms like generalized weakness. A basic metabolic panel will provide information on the patient's electrolyte levels, including potassium, and help determine if the weakness is due to an electrolyte imbalance. This allows for appropriate intervention to correct the imbalance and prevent further complications.
Choice C reason: Assessing for facial muscle spasms is relevant because hypokalemia can cause muscle cramps and spasms. However, it does not address the root cause of the weakness and does not lead to immediate intervention.
Choice D reason: Calling for a rapid response team is generally reserved for situations where the patient is experiencing acute, life-threatening symptoms requiring immediate intervention. Generalized weakness in the context of a patient on a potassium-wasting diuretic does not usually necessitate such an urgent response unless it progresses to more severe symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Monitoring the patient for shortness of breath or chest pain during the transfusion is a critical task that requires nursing judgment and immediate intervention if complications arise. It is not appropriate to delegate this task to unlicensed assistive personnel.
Choice B reason: Obtaining the patient's temperature and blood pressure before the transfusion is a task that can be safely delegated to nursing assistants. This task does not require the clinical judgment of a licensed nurse and is within the scope of practice for unlicensed assistive personnel.
Choice C reason: Double-checking the product numbers on the PRBCs with the patient ID band is a crucial safety step that must be performed by licensed nursing staff. This task ensures the correct blood product is given to the correct patient and involves verification that cannot be delegated to unlicensed personnel.
Correct Answer is B
Explanation
Choice A reason: Kidney failure is not a common immediate complication related to the patient's presentation of sudden right-sided weakness and difficulty speaking, which are indicative of a stroke. Although diabetes and hypertension can eventually lead to kidney issues, this is not an acute complication.
Choice B reason: Aspiration pneumonia is a potential complication of the patient's condition, especially given the presence of expressive aphasia. Patients with neurological deficits, particularly those affecting speech and swallowing, are at higher risk of aspirating food or liquids into the lungs, leading to pneumonia.
Choice C reason: Hypotension is not commonly a direct complication of a stroke, especially considering the patient's elevated blood pressure. Stroke patients often present with hypertension rather than hypotension.
Choice D reason: Heart failure, while related to the patient's underlying conditions like hypertension and possibly diabetes, is not an immediate complication of the acute neurological event described. The focus should be more on the neurological and respiratory complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.