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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. “They’ll protect your legs and heels from skin breakdown.”: While antiembolism stockings can provide some degree of protection against skin breakdown due to their snug fit, this is not their primary purpose. Their main function is to improve circulation and prevent blood clots, not to protect the skin.

B. “They’ll make it easier for you to do leg exercises after your surgery.”: Antiembolism stockings do not directly facilitate leg exercises. While they can help improve circulation which might indirectly aid in recovery, their primary purpose is to prevent the formation of blood clots in the lower extremities.

C. “They’ll improve your circulation to keep blood from pooling in your legs.”: This is correct. Antiembolism stockings, also known as compression stockings, are designed to apply pressure to your lower legs, helping to maintain blood flow and reduce discomfort and swelling. They can help prevent deep vein thrombosis (DVT), a type of blood clot that’s most common in the deep veins of your legs.

D. “They’ll help keep you warm immediately after your surgery.”: While antiembolism stockings might provide some warmth due to their material, this is not their primary function. Their main purpose is to improve circulation in the legs and prevent blood clots.

A. Review the client's toxicology laboratory report. B. Administer the Hamilton depression scale. C. Initiate one-to-one nursing observation. D. Make a contract with the client for weight gain.

Correct Answer is C

Explanation

(A) Review the client's toxicology laboratory report:
While reviewing the toxicology report is important to understand any substances that may have been ingested, it is not the immediate priority compared to ensuring the client's safety.

(B) Administer the Hamilton depression scale:
Administering the Hamilton depression scale can help assess the severity of the client's depression, but immediate safety measures take precedence over assessment tools upon admission after a suicide attempt.

(C) Initiate one-to-one nursing observation:
Initiating one-to-one nursing observation is the most immediate and crucial action to ensure the client's safety. After a suicide attempt, continuous observation is essential to prevent further self-harm and ensure the client's immediate safety.

(D) Make a contract with the client for weight gain:
While addressing anorexia nervosa and making a contract for weight gain is important for the client's long-term treatment plan, it is not the first priority. Ensuring immediate safety through continuous observation is the most critical initial step.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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