A nurse is admitting a client who reports excessive thirst, fever, and periods of confusion. The nurse suspects the client is experiencing heat exhaustion. Which of the following electrolyte imbalances should the nurse expect?

Hypernatremia

Hypocalcemia

Hyperkalemia

Hyperphosphatemia

Answer and Explanation

The Correct Answer is A

A. Hypernatremia: Excessive fluid loss through sweat, combined with insufficient fluid intake, can lead to hypernatremia (elevated sodium levels), often seen in heat exhaustion.
B. Hypocalcemia: Calcium levels are not typically affected by heat exhaustion.
C. Hyperkalemia: Potassium levels usually decrease due to sweating, not increase.
D. Hyperphosphatemia: Phosphate levels are not significantly altered in heat exhaustion.

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Correct Answer is D

Explanation

A. "You will need to fast for 2 hours before the procedure." Bone marrow aspiration typically does not require fasting. If the procedure involves sedation, the client may be instructed to fast for a certain period, but fasting is not a standard requirement for bone marrow aspiration.
B. "You will have the bone marrow taken from your femur." While the femur (thigh bone) can be a site for bone marrow aspiration, the most common site is the posterior iliac crest (the back of the pelvis). The nurse should clarify the exact site with the healthcare provider.
C. "You will not receive a local anesthetic agent for this procedure." Bone marrow aspiration is typically performed under local anesthesia to minimize discomfort at the site. The client will feel pressure during the procedure but should not experience pain due to the anesthesia.
D. "I will hold pressure on the site after the procedure." After a bone marrow aspiration, the nurse will apply pressure to the site to control any bleeding and help prevent hematoma formation. This is an important part of post-procedure care.

A. "Do you have any pain this morning?" B. "Is your pain the same as it has been?" C. "Could you rate your pain on a scale from 0 to 10?" D. "What does your pain feel like?"

Correct Answer is D

Explanation

A. "Do you have any pain this morning?": This is a yes/no question that doesn't provide information about the pain's quality.
B. "Is your pain the same as it has been?": This assesses changes in pain, not its quality.
C. "Could you rate your pain on a scale from 0 to 10?": This measures the intensity of pain, not its quality.
D. "What does your pain feel like?": Asking about the quality of pain focuses on its nature (e.g., sharp, dull, throbbing, or burning). This helps determine the pain's characteristics.

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A nurse is admitting a client who reports excessive thirst, fever, and periods of confusion. The nurse suspects the client is experiencing heat exhaustion. Which of the following electrolyte imbalances should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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