A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings show the nurse expect?
Hyperactive reflexes
Extreme thirst
Weak, irregular pulse
Hyperactive bowel sounds
The Correct Answer is C
A. Hypokalemia usually causes muscle weakness, decreased deep tendon reflexes, and cramps, not hyperreflexia.
B. While dehydration might be a consequence of vomiting and diarrhea, extreme thirst is not a typical symptom specifically related to hypokalemia. It's more associated with the body's response to fluid loss.
C. Potassium is essential for cardiac conduction. Hypokalemia can cause dysrhythmias, irregular pulse, and weak heart contractions due to decreased excitability of myocardial cells.
D. Hyperactive bowel sounds might be present in clients with gastrointestinal issues like diarrhea, but they are not directly caused by hypokalemia. They are more likely a consequence of the underlying gastrointestinal condition causing the electrolyte imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Correct Actions:
B. Test the pH of gastric aspirate.
Explanation: Testing the pH of gastric aspirate helps confirm that the NG tube is correctly positioned in the stomach. A pH of 4 or less generally indicates gastric placement. This step is crucial to avoid complications like aspiration and ensure proper feeding.
E. Check the tube's placement and patency.
Explanation: Ensuring that the tube is correctly positioned and patent (not blocked) is essential before administering feedings. This involves aspirating some of the gastric contents to confirm placement and flushing the tube with water to verify it is clear and functioning properly.
Incorrect Actions:
A. Discard residual gastric contents.
Explanation: While it is important to measure gastric residuals to assess the stomach's ability to handle the feeding, residuals are not discarded. Instead, they are measured and then returned to the stomach unless otherwise specified by the healthcare provider.
C. Auscultate sounds.
Explanation: Auscultation of bowel sounds is not typically required immediately before administering enteral feedings. However, assessing bowel sounds periodically can be part of overall monitoring to ensure proper gastrointestinal function.
D. Warm the formula to body temperature.
Explanation: Enteral feeding formulas are generally administered at room temperature, although some facilities may have specific protocols for warming. Most guidelines do not require warming formula to body temperature.
Correct Answer is B
No explanation
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