A nurse is assessing a patient with hypokalemia, she notes that the patient's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?

Assess the patient’s respiratory rate, rhythm, depth

Call the healthcare provider

Document findings and monitor the patient

Measure the patient’s pulse and blood pressure

Answer and Explanation

The Correct Answer is A

A. Assess the patient’s respiratory rate, rhythm, depth:

This is the correct action to take first. Hypokalemia can lead to respiratory muscle weakness, which can result in respiratory compromise or failure. Assessing the patient's respiratory rate, rhythm, and depth will help determine if there are any signs of respiratory distress or impending respiratory failure.

B. Call the healthcare provider:

While it's important to involve the healthcare provider, especially if there is a significant change in the patient's condition, assessing the patient's immediate respiratory status takes priority to ensure prompt intervention if respiratory distress is present.

C. Document findings and monitor the patient:

Documenting findings and ongoing monitoring are essential steps, but they come after addressing the patient's immediate needs, such as assessing respiratory status in this case.

D. Measure the patient’s pulse and blood pressure:

While vital signs are important, they may not immediately address the potential respiratory compromise associated with hypokalemia-induced muscle weakness. Assessing respiratory status is more directly relevant to the observed change in handgrip strength.

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Correct Answer is ["A","D","E"]

Explanation

A. Decreased plasma volume:Burn injuries cause a significant inflammatory response, leading to fluid shifts from the intravascular space to the interstitial space. This results in hypovolemia and decreased plasma volume, especially during the acute phase of burns.

B. Diuresis:Diuresis typically occurs after fluid resuscitation and stabilization of the client (in the later phase of burn recovery). In the initial phase, oliguria is more common due to hypovolemia and reduced renal perfusion.

C. Hypermagnesemia:Hypermagnesemia is not typically associated with burn injuries. Instead, clients with burns often experience hypomagnesemia due to fluid shifts, protein loss, and increased renal losses.

D. Capillary leak:Burn injuries lead to a systemic inflammatory response, causing capillary leak syndrome. This increases vascular permeability, allowing fluid, electrolytes, and proteins to leak into the interstitial spaces, contributing to edema and hypovolemia.

E. Loss of protein:Proteins are lost through damaged capillaries and open burn wounds, contributing to decreased oncotic pressure, edema, and a need for aggressive nutritional support to promote healing and recovery.

A. The transfusion will begin after the administration of 650 mg of acetaminophen {Tylenol). B. The blood will be held, and the health care provider will be notified C. The transfusion will begin after the administration of an antihistamine D. The transfusion will begin as prescribed

Correct Answer is A

Explanation

A. The transfusion will begin after the administration of 650 mg of acetaminophen (Tylenol).

This option suggests that the nurse would administer acetaminophen to lower the client's temperature and then proceed with the blood transfusion. While acetaminophen can be used to reduce fever, the decision to administer medication should be made by the healthcare provider after assessing the client's overall condition and determining the cause of the fever. Administering medication without proper evaluation and orders from the healthcare provider is not appropriate.

B. The blood will be held, and the health care provider will be notified.

This option is the correct choice. When a client has an elevated temperature before a blood transfusion, it is standard practice to hold the transfusion and notify the healthcare provider. An elevated temperature could indicate an underlying infection or another condition that needs to be evaluated before proceeding with the transfusion to ensure the client's safety.

C. The transfusion will begin after the administration of an antihistamine.

Administering an antihistamine would not be the appropriate action in response to an elevated temperature before a blood transfusion. Antihistamines are typically used to treat allergic reactions, not fevers. Holding the transfusion and notifying the healthcare provider to assess the situation would be the correct course of action.

D. The transfusion will begin as prescribed.

This option is not appropriate because starting the transfusion without addressing the elevated temperature could pose risks to the client's health. Elevated temperatures may indicate an underlying infection or other conditions that need to be evaluated before proceeding with the transfusion. Holding the transfusion and seeking further guidance from the healthcare provider is the recommended action in this scenario.

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A nurse is assessing a patient with hypokalemia, she notes that the patient's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

Correct Answer is A

Explanation

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