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 C
Explanation
Choice A reason: While blood glucose monitoring is essential for patients receiving TPN, it is not specifically necessary to obtain samples from a central line. Blood glucose levels can be monitored through peripheral blood samples.
Choice B reason: There is actually an increased risk of infection with central lines compared to peripheral lines due to the invasive nature of central line placement and its location. Proper aseptic technique is critical to minimize this risk.
Choice C reason: The hypertonic solution will be more rapidly diluted when given through a central line. This is a critical point because the central veins have a higher blood flow and larger volume, which helps to quickly dilute the hypertonic TPN solution. This reduces the risk of phlebitis and damage to the smaller peripheral veins, making central lines more suitable for infusing highly concentrated solutions like 25% dextrose.
Choice D reason: While a central line can allow for the rapid administration of infusions, this is not the primary reason for its use with TPN. The key factor is the dilution of the hypertonic solution, as central lines handle high osmolarity solutions better than peripheral veins.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Anorexia, nausea, and vomiting are not typical findings associated with Cushing syndrome. These symptoms can be related to other medical conditions but do not specifically indicate Cushing syndrome.
Choice B reason: Truncal obesity, thin extremities, and rounding of the face (moon face) are classic signs of Cushing syndrome. This condition leads to fat redistribution, resulting in increased fat around the trunk and face while the extremities appear thinner. The distinctive appearance of moon face is due to fat accumulation.
Choice C reason: Purplish streaks on the abdomen, also known as striae, are a common feature of Cushing syndrome. These stretch marks occur due to the excessive production of cortisol, which weakens the connective tissue, leading to skin changes.
Choice D reason: Hyperglycemia, or high blood sugar, is frequently seen in patients with Cushing syndrome. The excess cortisol increases glucose production and decreases insulin sensitivity, leading to elevated blood sugar levels.
Choice E reason: A bronzed appearance of the skin is not a typical finding of Cushing syndrome. This symptom is more commonly associated with Addison's disease, which involves adrenal insufficiency rather than excess cortisol production seen in Cushing syndrome.
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