A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia?
Restlessness
Hyperactive bowel sounds
Decreased deep-tendon reflexes
Bounding peripheral pulses
The Correct Answer is C
A. Restlessness:
Restlessness is not typically associated with hypokalemia. Instead, it may indicate anxiety, discomfort, or other factors unrelated to electrolyte imbalances.
B. Hyperactive bowel sounds:
Hyperactive bowel sounds are often associated with increased gastrointestinal motility, which may occur in conditions such as diarrhea or gastroenteritis. While electrolyte imbalances can contribute to gastrointestinal symptoms, hyperactive bowel sounds are not specific to hypokalemia.
C. Decreased deep-tendon reflexes:
Hypokalemia can lead to decreased deep-tendon reflexes due to its effects on nerve conduction. Potassium is essential for proper nerve and muscle function, and low levels can impair reflexes.
D. Bounding peripheral pulses:
Bounding peripheral pulses are not typically associated with hypokalemia. Instead, they may indicate increased cardiac output or volume overload, which can occur in conditions such as heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C. Respiratory acidosis
Rationale:
A) Metabolic acidosis: This occurs when there is an excess of acid in the body or a loss of bicarbonate, often due to conditions such as renal failure or severe diarrhea. In chronic bronchitis, the primary issue is related to respiratory function rather than metabolic disturbances.
B) Respiratory alkalosis: This condition results from hyperventilation, leading to excessive loss of carbon dioxide. It is unlikely in a client with chronic bronchitis, who typically experiences difficulty in exhaling fully rather than hyperventilating.
C) Respiratory acidosis: In chronic bronchitis, airflow obstruction and reduced gas exchange can lead to carbon dioxide retention, resulting in respiratory acidosis. Symptoms like dyspnea and increased work of breathing support this imbalance, as the body is unable to adequately expel carbon dioxide.
D) Metabolic alkalosis: This imbalance results from excessive bicarbonate or loss of hydrogen ions, often related to prolonged vomiting or diuretics. It is not characteristic of chronic bronchitis, where the primary concern is respiratory function rather than metabolic processes.
Correct Answer is C
Explanation
Answer: C. Orange ice pop
Rationale:
A) Ice cream: Although cold, ice cream can be thick and may stick to the throat, potentially causing discomfort and an urge to clear the throat, which could disrupt the healing tissue and increase bleeding risk.
B) Hot tea: Hot beverages can irritate the surgical site and increase the risk of bleeding due to the heat dilating blood vessels in the area. Cold or room temperature items are recommended post-tonsillectomy.
C) Orange ice pop: An orange ice pop is cold and soothing, which can reduce swelling and pain. Its smooth texture is easy on the throat and unlikely to cause irritation, making it an ideal snack post-tonsillectomy.
D) Cranberry juice: Cranberry juice is acidic and can irritate the throat, causing discomfort and possibly increasing inflammation at the surgical site. Non-acidic, cold foods are preferable to aid in comfort and healing.
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