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

Explanation

Choice A rationale

The rubella vaccine is a live vaccine, which means it contains a weakened version of the virus. Because the virus is still active, live vaccines are not safe for pregnant people. There is a small chance they may pass the virus to the baby. Therefore, it is recommended that adults of childbearing age should avoid getting pregnant for at least four weeks after receiving the MMR vaccine. This is to ensure the safety of both the mother and the baby.

Choice B rationale

This statement is incorrect. The rubella vaccine does not require additional shots after each baby with Rh-positive blood. The rubella vaccine is typically administered in childhood and provides long-term protection.

Choice C rationale

This statement is also incorrect. The rubella vaccine does not require additional shots in 1 month and again in 6 months. The vaccine provides long-term protection and does not typically require frequent boosters.

Choice D rationale

While it’s true that some vaccines can cause side effects such as fever and vomiting, these are not common side effects of the rubella vaccine. Therefore, this statement is not entirely accurate.

Correct Answer is []

Explanation

Potential Condition:

B. Type 1 diabetes mellitus

The client’s symptoms of fatigue, blurred vision, dizziness, and headache, along with a high blood glucose level and HbA1C, suggest that they are experiencing hyperglycemia, a condition common in individuals with Type 1 diabetes mellitus.

Actions to Take:

B. Teach the client about the signs of hyperglycemia.
D. Assess the client’s feet for sensation.

Teaching the client about the signs of hyperglycemia will help them recognize when their blood sugar is high and take appropriate action. Assessing the client’s feet for sensation is also important as diabetes can lead to peripheral neuropathy, which can result in a loss of sensation in the feet.

Parameters to Monitor:

B. Blood pressure
D. Fingerstick blood glucose

Monitoring the client’s blood pressure is important as hypertension can be a complication of diabetes. Regularly checking the client’s fingerstick blood glucose levels will help ensure that their diabetes is being effectively managed.

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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 client’s prenatal laboratory findings reveal no immunity to rubella.The health care provider orders the rubella vaccine.The nurse concludes that teaching about this medication is effective when the client states which of the following?

Correct Answer is A

Explanation

Correct Answer is []

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?