A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

Dyspnea

Oliguria

Pitting edema

Fatigue

Answer and Explanation

The Correct Answer is D

Hypokalemia is a low serum potassium level, usually below 3.5 mEq/L. It can be caused by diuretics that increase potassium excretion, such as thiazides or loop diuretics. Potassium is essential for normal muscle and nerve function, and hypokalemia can impair cardiac, skeletal, and smooth muscle activity. Symptoms of hypokalemia include fatigue, weakness, muscle cramps, arrhythmias, constipation, and hyporeﬂexia.

Dyspnea is difficulty or labored breathing that can be caused by various respiratory or cardiac conditions, such as asthma, pneumonia, pulmonary edema, or heart failure. It is not a specific sign of hypokalemia, although severe hypokalemia can aﬀect respiratory muscle function and cause respiratory failure.
Oliguria is a reduced urine output, usually less than 400 mL per day or 30 mL per hour. It can be caused by various renal or ﬂuid balance disorders, such as acute kidney injury, dehydration, or shock. It is not a specific sign of hypokalemia, although severe hypokalemia can impair renal function and cause renal failure.
Pitting edema is a swelling of the tissues that leaves an indentation when pressed with a finger. It can be caused by various ﬂuid retention disorders, such as heart failure, liver cirrhosis, or nephrotic syndrome. It is not a specific sign of hypokalemia, although severe hypokalemia can aﬀect ﬂuid and electrolyte balance and cause edema.

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Correct Answer is A

Explanation

The nurse should identify that this client has multiple risk factors for cardiovascular disease, such as hypertension, obesity, and smoking. These factors can increase the risk of atherosclerosis, coronary artery disease, stroke, and peripheral vascular disease.

Depression is wrong because it is not directly related to the client's physical examination findings. Depression may have other risk factors, such as genetics, stress, trauma, or substance abuse.

Thyroid disease is wrong because it is not directly related to the client's physical examination findings. Thyroid disease may have other risk factors, such as autoimmune disorders, iodine deficiency, or radiation exposure.

Testicular cancer is wrong because it is not directly related to the client's physical examination findings. Testicular cancer may have other risk factors, such as cryptorchidism, family

A. "Place the client on his back." B. "Restrain the client." C. "Insert a padded tongue blade into the client's mouth." D. "Move objects away from the client."

Correct Answer is D

Explanation

Moving objects away from the client is an important action to take during a seizure, as it can prevent injury and protect the client from harm.

"Place the client on his back." is not correct, as it can cause airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.

"Restrain the client." is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.

"Insert a padded tongue blade into the client's mouth." is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.

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A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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