A nurse is assessing a client who started taking furosemide 2 days ago and has a potassium level of 3.1 mEq/L (3.5 to 5 mEq/L). Which of the following findings should the nurse expect?
Muscle rigidity of the extremities
Bounding radial pulses
Depressed deep tendon reflexes
Increased bowel motility
The Correct Answer is C
A. Muscle rigidity of the extremities: This finding is more indicative of hyperkalemia or severe electrolyte imbalances but is not a common symptom of hypokalemia.
B. Bounding radial pulses: This finding is more associated with hypervolemia or hyperkalemia, not with hypokalemia caused by furosemide.
C. Depressed deep tendon reflexes: This is the correct response, as low potassium levels (hypokalemia) can lead to diminished reflexes due to its role in neuromuscular function.
D. Increased bowel motility: This is incorrect, as hypokalemia typically results in decreased bowel motility and may cause constipation rather than increased motility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Mostly cloudy: This option appears to be incorrectly stated. It does not pertain to a critical client assessment related to morphine administration.
B. Apical heart rate: Monitoring the heart rate is important, but respiratory depression is a more immediate and life-threatening concern with morphine administration, so it is not the first priority.
C. Blood pressure: Morphine can cause hypotension, but this is not as critical as respiratory depression, which must be assessed first in opioid administration.
D. Respiratory rate: The most critical assessment when administering morphine is the respiratory rate, as opioid medications like morphine can cause respiratory depression, which can be life-threatening if not addressed.
E. Level of consciousness: While important, changes in consciousness typically follow respiratory depression, so assessing the respiratory rate takes priority.
Correct Answer is D
Explanation
A. Acetylcysteine is not indicated for gastrointestinal bleeding; other treatments are used for that condition.
B. Acute bronchospasm is treated with bronchodilators rather than acetylcysteine.
C. Morphine toxicity requires other interventions, such as opioid antagonists (e.g., naloxone), and acetylcysteine is not effective in this case.
D. Acetylcysteine is specifically indicated for acetaminophen toxicity as it acts as an antidote, replenishing glutathione stores and preventing liver damage from toxic metabolites.
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