A nurse is caring for a client who is taking potassium chloride supplements daily for hypokalemia. Which of the following findings should indicate to the nurse the supplements are effective?
Decreased deep-tendon reflexes
Regular heart rhythm
Hypoactive bowel sounds
Respiratory rate 10/min
The Correct Answer is B
A) Decreased deep-tendon reflexes: Decreased deep-tendon reflexes can indicate hyperkalemia, which occurs when potassium levels are too high. This is not a sign of effective potassium chloride supplementation for hypokalemia, as it suggests an imbalance in the opposite direction.
B) Regular heart rhythm: A regular heart rhythm is a key indicator that potassium levels are within the normal range. Potassium is crucial for proper cardiac function, and maintaining an adequate level helps prevent arrhythmias and supports effective heart rhythms.
C) Hypoactive bowel sounds: Hypoactive bowel sounds can be associated with various conditions, including electrolyte imbalances like hypokalemia. However, the presence of hypoactive bowel sounds does not directly indicate that potassium chloride supplementation is effective.
D) Respiratory rate 10/min: A respiratory rate of 10/min is below the normal range and can be a sign of respiratory depression or other issues. This finding does not relate to the effectiveness of potassium chloride supplements in treating hypokalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Monitor the client for an elevated RBC count.: While an elevated white blood cell count (WBC) is more indicative of appendicitis, an elevated RBC count is not typically used to diagnose appendicitis.
B. Instruct the client to not eat food or drink liquids.: This is important as it prepares the client for a potential surgical procedure. If the appendix is inflamed and surgery is necessary, the client should not eat or drink to prevent complications related to anesthesia and surgery.
C. Administer an enema to the client.: Administering an enema is not recommended as it can increase the risk of perforation of the appendix, which is a serious complication.
D. Maintain the client in a supine position.: While maintaining a supine position may be necessary, it is not as critical as ensuring the client remains NPO (nil per os) in preparation for possible surgery. The position is less of a priority compared to dietary restrictions in this scenario.
Correct Answer is A
Explanation
A. Check skin temperature distal to the injury with the dorsum of the hand.: Assessing skin temperature distal to the injury is an important part of evaluating neurovascular status. It helps to identify any changes in circulation or potential complications like ischemia. The dorsum of the hand is commonly used as it provides a good comparison to the temperature of the affected extremity.
B. Press the heel of the foot to determine capillary refill.: While capillary refill is an important assessment, it is usually measured by pressing the nail beds or pads of the fingers and toes, not by pressing the heel. This method does not provide a reliable indication of neurovascular status.
C. Monitor sensation by palpating the pad of the great toe with a blunt needle.: While assessing sensation is important, it is typically done using a light touch or pinprick, rather than palpating with a blunt needle. The use of a needle is not standard practice for this type of assessment.
D. Compare the color of the skin proximal to the injury with the other extremity.: Comparing the skin color distal to the injury with the unaffected extremity is more relevant for evaluating neurovascular status. Proximal comparison is less effective in assessing circulation and potential issues related to the injury.
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