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 C

Explanation

A. Obtain the client's peak expiratory flow volume: This is unnecessary in this context and not a routine assessment post-tonsillectomy.
B. Encourage the client to cough: Coughing can irritate the surgical site and increase the risk of bleeding.
C. Place the client in a semi-Fowler's position. Semi-Fowler's position promotes optimal airway clearance and reduces the risk of aspiration or airway obstruction.
D. Encourage the client to use a straw to sip cool liquids: Straws are contraindicated because the suction action can disrupt the surgical site and cause bleeding.

A. Soft, unformed stools B. Purplish stoma C. Noticeable stool odor D. Slight bleeding around the stoma

Correct Answer is B

Explanation

A. "Soft, unformed stools.": This can be expected, depending on the location of the colostomy.
B. "Purplish stoma." A purplish stoma suggests compromised blood flow, which is a medical emergency.
C. "Noticeable stool odor.": Odor is normal with colostomies unless accompanied by infection or other symptoms.
D. "Slight bleeding around the stoma.": Minimal bleeding during cleaning is common and expected initially.

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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

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