A nurse is collecting data from a client who is receiving IV fluid replacement to treat diarrhea but now has oliguria. Laboratory results include a potassium level of 5.6 mEq/L. The nurse should report which of the following findings to the provider immediately?
Muscle weakness
Paresthesias
Abdominal cramps
Palpitations
The Correct Answer is D
Choice A Reason:
Muscle weakness is incorrect. Muscle weakness can be a symptom of hyperkalemia (elevated potassium levels). However, it is not the most urgent symptom, and the provider should be informed to address the underlying cause.
Choice B Reason:
Paresthesias is incorrect. Paresthesias (tingling or numbness) can also occur with hyperkalemia. While important to assess, it may not be the most urgent symptom requiring immediate attention.
Choice C Reason:
Abdominal cramps is incorrect. Abdominal cramps can be associated with hyperkalemia, but they are not the most critical symptom. It's essential to address the underlying cause, but it may not require immediate intervention compared to other symptoms.
Choice D Reason:
Palpitations is correct. Palpitations are a concerning symptom, especially in the context of hyperkalemia. Elevated potassium levels can lead to cardiac arrhythmias, and palpitations may be indicative of serious cardiac complications. This is a critical finding that requires immediate attention from the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Increase in fluid requirements is incorrect. An increase in fluid requirements is more likely to contribute to changes in fluid balance and not necessarily to long-term weight gain. While short-term fluctuations in fluid retention can affect weight, sustained weight gain is not typically attributed to increased fluid intake.
Choice B Reason:
Decrease in vitamin intake is incorrect. While inadequate vitamin intake can have various health implications, direct weight gain is not a typical outcome. However, a poor diet that lacks essential nutrients, including vitamins, can lead to overall health issues, potentially influencing weight management indirectly.
Choice C Reason:
Increase in protein requirements is incorrect. An increase in protein requirements, in itself, is not likely to result in weight gain. However, a diet with an excess of calories, including proteins, can contribute to weight gain. It's essential to consider the overall dietary balance and caloric intake.
Choice D Reason:
Decrease in muscle mass is correct. Decrease in muscle mass, known as sarcopenia, is a common age-related change. As muscle mass decreases, there can be a reduction in metabolic rate, potentially leading to weight gain. Additionally, the loss of muscle may be accompanied by an increase in fat mass, contributing to changes in overall body composition.
Correct Answer is B
Explanation
Choice A Reason:
To an insurance agency in regard to a life insurance policy . This situation is incorrect. Generally, disclosure of health information to an insurance agency requires the client's written consent.
Choice B Reason:
To a medical interpreter service on behalf of a client. This situation is correct. In healthcare settings, it is generally acceptable to share limited health information with a medical interpreter service to facilitate communication with the client, especially if the client has limited proficiency in the primary language spoken in the healthcare setting. The interpreter is bound by confidentiality rules similar to healthcare providers.
Choice C Reason:
To a family member when the client is not available. This situation is incorrect. Disclosing health information to a family member typically requires the client's consent unless there are specific circumstances, such as emergencies, where the healthcare provider may need to act in the best interest of the client.
Choice D Reason:
To an employer for a pre-employment screening. This situation is incorrect. Disclosing health information to an employer typically requires the client's written consent. Employment-related health information is usually protected by privacy laws.
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