The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?

Client's serum pH is 7.41

Client has a stage 2 sacral wound

Client requires continuous nasogastric suction

Client has a history of adrenal insufficiency

Answer and Explanation

The Correct Answer is C

A. Client's serum pH is 7.41: This is within the normal range for blood pH (7.35-7.45) and does not specifically indicate a potassium deficit.
B. Client has a stage 2 sacral wound: This is related to skin integrity and does not directly impact potassium levels.
C. Client requires continuous nasogastric suction: Continuous nasogastric suction can lead to the loss of potassium as it removes gastric contents, which may include electrolytes.
D. Client has a history of adrenal insufficiency: While adrenal insufficiency can affect electrolyte balance, continuous nasogastric suction is a more immediate risk for potassium deficit.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Total urine output 45 mL during past 3 hours: Appropriate
Rationale: Epidural anesthesia can affect bladder function, leading to reduced urine output. A total urine output of 45 mL in 3 hours is low and should be reported as it might indicate urinary retention or decreased kidney function.
Nausea and vomiting: Inappropriate
Rationale: Nausea and vomiting are not typically a direct concern related to epidural anesthesia unless they are severe or persistent. These symptoms are more commonly associated with general anesthesia or postoperative complications, but they are not immediate concerns specific to epidural block.
Clear fluid leaking from insertion site: Appropriate
Rationale: Clear fluid leaking from the epidural insertion site could indicate cerebrospinal fluid leakage or other complications. This should be reported immediately to assess for potential complications such as an epidural hematoma or infection.
Severe headache: Appropriate
Rationale: A severe headache following an epidural block could be a sign of a post-dural puncture headache, which is a known complication of epidural anesthesia. It should be reported to the healthcare provider for further evaluation and management.
Left knee pain 3 out of 10: Inappropriate
Rationale: Pain at a level of 3 out of 10 is relatively mild and may be expected following surgery. While it is important to monitor and manage pain, this level of pain is not usually an immediate concern related to the epidural anesthesia unless other symptoms are present.

A. Chest x-ray results B. Serum osmolality C. Intake and output record D. Serum glucose level

Correct Answer is A

Explanation

A. Chest x-ray results: This is the correct choice. After central venous catheter insertion, a chest x-ray is crucial to confirm correct catheter placement and to rule out complications such as pneumothorax or catheter malposition.
B. Serum osmolality: While serum osmolality can provide information about fluid and electrolyte balance, it is not directly related to verifying catheter placement or the immediate post-insertion assessment.
C. Intake and output record: Although important for monitoring fluid balance, the intake and output record does not confirm the proper placement of the central venous catheter.
D. Serum glucose level: This is not relevant to verifying the catheter placement or ensuring proper functioning immediately after insertion.

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The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

A client has just undergone a bedside central venous catheter insertion using ultrasound guidance. The nurse knows to check which diagnostic result before initiating the client's prescribed intravenous solution flow rate at 100 mL/hr?

Correct Answer is A

Explanation

The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

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