A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
The client who has a chest tube to water seal
The client who has a tracheostomy tube attached to humidified oxygen
The client who has an indwelling urinary catheter to gravity drainage
The client who has a nasogastric (NG) tube to suction
The Correct Answer is D
A. A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.
B. A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.
C. An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.
D. A client with an NG tube to suction may experience loss of gastric contents, which can lead to the loss of electrolytes, including potassium. This places the client at risk for hypokalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A - Using a stiff toothbrush is not appropriate for oral care in immobile clients, as it can irritate or damage the gums and oral tissues. A soft-bristled toothbrush is recommended to ensure gentle cleaning.
B - Turning the client on his side is the correct action to prevent aspiration. This position allows fluids and saliva to drain from the mouth, reducing the risk of aspiration, which is critical for immobile clients.
C - Using the thumb and index finger to keep the client’s mouth open can lead to accidental injury. Instead, a padded tongue blade should be used to maintain the client’s mouth open safely during oral care.
D - Applying petroleum jelly to the lips should be avoided, as it is oil-based and can increase the risk of aspiration if inhaled. A water-based lubricant or lip balm should be used instead.
Correct Answer is D
Explanation
A. Independently disposing of the remaining medication may not be in compliance with facility policies and could potentially interfere with an investigation into how the medication was left unattended.
B. Returning the medication to the unit's stock for future use is not appropriate, as the vial is already open and its integrity may be compromised.
C. Administering the medication to other clients is absolutely not an option. This could lead to serious harm or even fatal consequences for the other clients involved.
D. When a nurse discovers an open vial of medication left unattended, it is a serious safety concern. The nurse should report the discrepancy immediately to the appropriate personnel or supervisor. This ensures that the situation is addressed promptly and that necessary actions are taken to prevent potential harm to clients.
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