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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Nursing supervisors generally oversee nursing staff and ensure that patient care standards are being met, but they are not primarily responsible for developing individualized plans of care.

Choice B reason: Registered nurses (RNs) are trained and licensed to develop individualized plans of care that include nursing diagnoses, interventions, and outcomes. They work closely with patients to understand their needs and create a plan that supports their health goals, including self-management care.

Choice C reason: Health care providers, such as medical doctors (MDs) or nurse practitioners (NPs), are responsible for diagnosing and treating medical conditions, but the development of detailed nursing care plans is typically outside their primary scope of practice.

Choice D reason: Licensed practical/vocational nurses (LPN/VN) provide basic nursing care and assist with patient care activities, but they do not generally develop comprehensive nursing care plans, which require the higher level of training and education that RNs receive.

A. Urine output of 30 mL/hr B. Blood pressure is 90/40 C. IV site is infiltrated D. Oral fluid intake of 100 mL for 8 hours

Correct Answer is B

Explanation

Choice A reason: Urine output of 30 mL/hr is concerning as it is on the lower end of normal and can indicate dehydration or impaired renal function. However, in this context, it is less immediately alarming compared to severely low blood pressure.

Choice B reason: Blood pressure of 90/40 is critically low and indicates hypotension, which can be a sign of severe dehydration or shock, especially in a patient with ongoing nausea and vomiting. This requires immediate attention and intervention to stabilize the patient and prevent further complications.

Choice C reason: An infiltrated IV site is a problem that needs to be addressed to ensure proper administration of fluids and medications. However, it is not as immediately life-threatening as hypotension.

Choice D reason: Oral fluid intake of 100 mL for 8 hours is inadequate, suggesting that the patient may be dehydrated. While concerning, it is not as acutely critical as low blood pressure, which directly affects perfusion and organ function.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In any clinical setting, which health care team member is responsible for developing an individualized plan of care that includes nursing diagnoses, interventions, and outcomes, including the patient's self-management care plan?

Correct Answer is B

Explanation

The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?

Correct Answer is B

Explanation

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