A nurse is caring for a client who is taking a glucocorticoid. Which of the following findings should indicate to the nurse the client is experiencing hypokalemia? (Select all that apply.)
Muscle weakness.
Hyperactive bowel sounds.
Tingling of fingers.
Peaked T waves.
Fatigue.
Correct Answer : A,E
Choice A rationale
Muscle weakness is a common symptom of hypokalemia due to decreased potassium levels affecting muscle function.
Choice E rationale
Fatigue is another symptom of hypokalemia as low potassium levels can impair cellular function and energy production.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The nurse should first address the client’s elevated temperature followed by administering fluids.
So, the complete sentence would be: The nurse should first address the client’s elevated temperature followed by administering fluids.
Certainly! Let’s break down the situation and the rationale behind the priorities:
Elevated Temperature
The client’s temperature spiked significantly from 36.7°C (98.1°F) to 40.2°C (104.4°F) within a short period. This rapid increase is concerning for several reasons:
- Risk of Hyperthermia: A temperature of 40.2°C is dangerously high and can lead to hyperthermia, which can cause damage to body tissues and organs if not promptly addressed.
- Signs of Infection or Sepsis: Such a high fever could indicate a postoperative infection or sepsis, both of which require immediate attention.
- Physiological Stress: Elevated temperatures increase metabolic demands, which can exacerbate other symptoms like tachycardia (high heart rate) and hypotension (low blood pressure).
Administering Fluids
After addressing the elevated temperature, the next priority is to administer fluids. Here’s why:
- Hypotension (Low Blood Pressure): The client’s blood pressure dropped from 110/75 mm Hg to 90/60 mm Hg. This hypotension could be due to several factors, including dehydration, fever, or a systemic inflammatory response.
- Tachycardia (High Heart Rate): The client’s heart rate increased from 65/min to 125/min. This could be a compensatory mechanism for the low blood pressure or a response to the fever. Administering fluids can help stabilize the blood pressure and reduce the heart rate.
- Preventing Shock: Ensuring adequate fluid volume is crucial to prevent hypovolemic shock, which can occur if the body loses too much fluid or blood.
Immediate Actions Taken
The nurse already administered acetaminophen and applied ice packs to help reduce the fever, which are appropriate initial steps. However, continuous monitoring and additional interventions, such as fluid administration, are necessary to stabilize the client’s condition.
Summary
In summary, the nurse should first address the client’s elevated temperature to prevent potential complications from hyperthermia and then administer fluids to stabilize blood pressure and heart rate. This approach prioritizes the most immediate threats to the client’s health and ensures a comprehensive response to the symptoms presented.
Correct Answer is C
Explanation
Choice A rationale
Metoclopramide is not used to suppress cough. It is primarily used to treat nausea, vomiting, and gastroparesis.
Choice B rationale
Metoclopramide does not have a primary effect on muscle relaxation. Its main action is to increase gastrointestinal motility.
Choice C rationale
Reduced nausea is a primary outcome for evaluating the effectiveness of metoclopramide. It is commonly prescribed to manage nausea and vomiting.
Choice D rationale
Metoclopramide is not typically used to decrease pain. Its primary indications are related to gastrointestinal symptoms.
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