A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?
Hyperactive reflexes
Hyperactive bowel sounds
Weak, irregular pulse
Extreme thirst
The Correct Answer is C
A: Hypokalemia is associated with hypoactive reflexes, not hyperactive reflexes.
B: Hyperactive bowel sounds are more indicative of hyperkalemia, not hypokalemia.
C: Weak, irregular pulse is a common manifestation of hypokalemia and reflects the impact of potassium on cardiac function.
D: Extreme thirst is not a typical symptom of hypokalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The drip chamber should not be filled completely with blood, as this can cause clotting and occlusion.
B. The blood should not be infused for more than 4 hr, as this increases the risk of bacterial contamination and transfusion reactions.
C. Medications are usually administered separately from blood products to avoid incompatibility.
D. The packed RBCs should be connected by Y tubing to normal saline to prevent hemolysis and maintain fluid balance. This is an expected finding because it allows the nurse to flush the line with normal saline before and after the blood transfusion, and to switch to normal saline in case of a transfusion reaction.
Correct Answer is B
Explanation
A. While cold packs might be used for certain conditions, measuring the circumference of both upper arms is the priority in this situation.
B. Swelling of the arm above the PICC insertion site can indicate a complication such as thrombophlebitis, which is inflammation and clotting of the vein. The nurse should measure the circumference of both upper arms and compare them to detect any difference in size, which can indicate edema due to impaired venous return. This is the first action the nurse should take because it is an assessment step that can provide objective data to guide further interventions.
C. Swelling above the PICC insertion site could indicate complications such as infiltration, and the provider needs to be informed promptly. However, the nurse should first measure the circumference of both upper arms first.
D. Removing the PICC line should be done under the guidance of a healthcare provider, and it is not the first action to take.
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