A nurse is caring for four clients who have various types of drainage tubes.
Which of the following clients should the nurse identify as being at risk for hypokalemia?

The client who has an indwelling urinary catheter to gravity drainage

The client who has a chest tube to water seal

The client who has a nasogastric (NG) tube to suction

The client who has a tracheostomy tube attached to humidified oxygen

Answer and Explanation

The Correct Answer is C

Choice A rationale

The client who has an indwelling urinary catheter to gravity drainage is not at risk for hypokalemia. The kidneys regulate the balance of potassium by removing excess potassium into the urine. The use of a urinary catheter would not affect this process.

Choice B rationale

The client who has a chest tube to water seal is not at risk for hypokalemia. Chest tubes are used to treat conditions that can cause the lung to collapse, such as pneumothorax, hemothorax, or pleural effusion. They do not affect the body’s potassium levels.

Choice C rationale

The client who has a nasogastric (NG) tube to suction is at risk for hypokalemia. Hypokalemia, or low potassium levels, can occur with loss of gastric fluids because these fluids contain potassium. With an NG tube to suction, these fluids are being removed from the body, which can lead to a decrease in potassium levels.

Choice D rationale

The client who has a tracheostomy tube attached to humidified oxygen is not at risk for hypokalemia. A tracheostomy tube allows air to enter the lungs. It does not affect the body’s potassium levels.

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

Explanation

Choice A rationale

Fetal motion is indeed evaluated during a biophysical profile. It assesses the health of the baby by observing its movements16.

Choice B rationale

Fetal neck translucency is not evaluated during a biophysical profile. It is usually measured during an ultrasound examination in the first trimester of pregnancy as a part of screening for chromosomal abnormalities.

Choice C rationale

Fetal gender is not evaluated during a biophysical profile. The focus of a biophysical profile is on the baby’s health, not its gender16.

Choice D rationale

Fetal breathing is indeed evaluated during a biophysical profile. It assesses the health of the baby by observing its breathing movements16.

Choice E rationale

Amniotic fluid volume is indeed evaluated during a biophysical profile. It assesses the health of the baby by measuring the amount of amniotic fluid surrounding the fetus in the uterus16.

A. A client diagnosed with preeclampsia reports epigastric pain and unresolved headache B. A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions C. A client diagnosed with preeclampsia has 2+ proteinuria and 2+ patellar reflexes D. A client at 28 weeks of gestation receiving terbutaline reports fine tremors

Correct Answer is A

Explanation

Choice A rationale

A client diagnosed with preeclampsia reporting epigastric pain and unresolved headache is a serious concern. Epigastric pain could indicate severe liver involvement, and a persistent headache could be a sign of progressing neurological involvement, both of which are severe features of preeclampsia. These symptoms suggest the condition may be worsening to eclampsia, a life-threatening complication characterized by the onset of seizure activity or coma in a woman with preeclampsia. Immediate medical attention is necessary to prevent further complications.

Choice B rationale

A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing preterm labor. However, emotional distress and contractions do not necessarily indicate a medical emergency. It’s important to monitor the situation, but it does not need to be immediately reported to the provider.

Choice C rationale

A client diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes are expected findings. Proteinuria is a common sign of preeclampsia, and hyperreflexia can occur due to increased neuromuscular irritability. While these should be monitored, they do not need to be immediately reported to the provider.

Choice D rationale

A client at 28 weeks of gestation receiving terbutaline reporting fine tremors is an expected side effect of the medication. Terbutaline, a beta-adrenergic agonist, can cause tremors by stimulating the nervous system. While it may be uncomfortable for the client, it is not a medical emergency.

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A nurse is caring for four clients who have various types of drainage tubes.Which of the following clients should the nurse identify as being at risk for hypokalemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is about to undergo a biophysical profile.The patient asks the nurse what will be evaluated during this test.Which of the following should the nurse include? (Select all that apply.)

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

Explanation

As a nurse caring for a group of clients on an intrapartum unit, which of the following findings should be immediately reported to the provider?

Correct Answer is A

Explanation

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A nurse is caring for four clients who have various types of drainage tubes.
Which of the following clients should the nurse identify as being at risk for hypokalemia?