A client’s bloodwork indicates that he has severe hypokalemia.
What is a priority nursing intervention?

Place the client on a cardiac monitor.

Administer a laxative as ordered.

Place the client on seizure precautions.

Restrict high potassium foods.

Answer and Explanation

The Correct Answer is A

This is because hypokalemia (low potassium level in the blood) can cause abnormal heart rhythms (arrhythmia) that can be life-threatening and require urgent medical attention. A cardiac monitor can help detect and treat any arrhythmia that may occur.

Choice B is wrong because administering a laxative can worsen hypokalemia by causing more potassium loss through the digestive tract. Laxative use is one of the possible causes of hypokalemia.

Choice C is wrong because placing the client on seizure precautions is not a priority intervention for hypokalemia. Seizures are not a common symptom of hypokalemia, although muscle weakness and cramps may occur.

Choice D is wrong because restricting high potassium foods is not a priority intervention for hypokalemia. In fact, increasing potassium intake through foods or supplements may be helpful in less serious cases of hypokalemia. However, this should be done according to the doctor’s recommendation and with careful monitoring of blood potassium levels.

Normal blood potassium levels for an adult range from 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than 2.5 mmol/L) can be life threatening.

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Correct Answer is ["A","B"]

Explanation

A cultural assessment is a systematic way to identify the beliefs, values, meanings, and behaviours of people while considering their history, life experiences, and social and physical environments. A nurse should include reviewing all ordered treatments in relation to the client’s culture and listening to the client’s perceptions as part of a cultural assessment.

These actions show respect for the client’s preferences and facilitate communication and understanding.

Choice C is wrong because explaining the purpose of the treatments without regard to the client’s culture may be insensitive or inappropriate for some clients who have different beliefs or practices about health and illness. Choice D is wrong because acknowledging that the client will have to adapt their perceptions to the dominant culture may be disrespectful or oppressive for some clients who value their cultural identity and diversity.

A. Chronic ocular pain related to stress, fatigue, and certain triggers. B. Pain and sensitivity in the upper extremities and neck. C. Dull joint pain that accompanies physical exertion and which is relieved with rest. D. Eight tender points in the legs and arms; insomnia; and fatigue.

Correct Answer is D

Explanation

This is because fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Fibromyalgia often co-exists with other conditions, such as irritable bowel syndrome, chronic fatigue syndrome, migraine and other types of headaches. One of the main symptoms of fibromyalgia is widespread pain that has lasted for at least three months. To be considered widespread, the pain must occur on both sides of your body and above and below your waist. The pain could also be felt in specific areas called tender points. These are places on the body where even light pressure causes pain. There are 18 possible tender points on the body. Having pain in at least 11 of these points is one way to help diagnose fibromyalgia.

Choice A is wrong because chronic ocular pain related to stress, fatigue, and certain triggers is not a typical symptom of fibromyalgia.

Ocular pain is more likely to be caused by other conditions, such as dry eye syndrome, glaucoma, or eye infections.

Choice B is wrong because pain and sensitivity in the upper extremities and neck are not enough to indicate fibromyalgia. The pain must be widespread and affect both sides of the body and above and below the waist. Choice C is wrong because dull joint pain that accompanies physical exertion and which is relieved with rest is not a characteristic of fibromyalgia. The pain associated with fibromyalgia is often described as a constant dull ache that does not improve with rest. It may also be accompanied by other symptoms, such as fatigue, cognitive difficulties, and sleep problems.

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A client’s bloodwork indicates that he has severe hypokalemia. What is a priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a cultural assessment with a client; the nurse should include which of the following? (Select All That Apply).

Correct Answer is ["A","B"]

Explanation

The nurse identifies chronic pain as an appropriate nursing priority (or problem/diagnosis) for a client with fibromyalgia. Which manifestation did the client most likely report that caused the nurse to select this priority?

Correct Answer is D

Explanation

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

A nurse is discussing the reporting of elder abuse with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Which of the following nursing diagnoses would typically NOT be associated with anemia?

A client is admitted with an exacerbation of COPD. He has a long history of chronic bronchitis. What physical finding does the nurse expect in a client with chronic bronchitis?

A nurse is assisting with teaching a newly licensed nurse about ethical principles. The nurse should include that working to not cause harm to a client, while trying to achieve the best possible outcome, is an example of which of the following ethical principles?

Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

A nurse is caring for a client with chronic fatigue syndrome. Which of the following criteria were used to assist in making this diagnosis? Select all that apply.

Signs of hemolytic anaemias include:

A client’s bloodwork indicates that he has severe hypokalemia.
What is a priority nursing intervention?