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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason:

Rubbing the puncture site with an alcohol pad is inappropriate. Rubbing the puncture site with an alcohol pad can cause vasoconstriction and make it more difficult to obtain a blood sample.

Choice B Reason:

Applying firm pressure to the puncture site is inappropriate. Applying firm pressure can further reduce blood flow to the puncture site, making it more challenging to collect an adequate blood sample.

Choice C Reason:

Wrapping the client's hand in a warm washcloth is appropriate. Applying a warm compress to the puncture site can help dilate the blood vessels and improve blood flow, making it easier to obtain a sufficient blood sample. This is especially beneficial for older adults who may have reduced blood flow to the extremities.

Choice D Reason:

Having the client raise his hand is inappropriate. Raising the hand may not be as effective as applying a warm washcloth in promoting blood flow to the puncture site. The warm washcloth helps to encourage vasodilation and improve the chances of obtaining an adequate blood sample.

A. Allow the family to participate in washing the client's body. B. Provide the family with an eagle feather for the client's hair. C. Encourage the family to chant a mantra before moving the body. D. Dress the client in a special amulet provided by the family.

Correct Answer is A

Explanation

Choice A Reason:
Allowing the family to participate in washing the client's body is appropriate. In Islamic tradition, it's customary for family members or individuals of the same gender to participate in washing the deceased's body. This practice is a part of the Islamic ritual of ghusl (ritual washing). It's respectful and important to honor the religious and cultural customs of the deceased and their family.

Choice B Reason:
Providing the family with an eagle feather for the client's hair is inappropriate. In Islamic traditions, the use of eagle feathers or any specific animal-related items isn't a part of postmortem care rituals. Additionally, incorporating items from other traditions or cultures might not align with the religious practices or beliefs of the deceased and their family.

Choice C Reason:
Encouraging the family to chant a mantra before moving the body is inappropriate. Chanting mantras isn't a practice in Islamic postmortem care. Islamic rituals involve specific prayers and actions according to the teachings of Islam, and chanting mantras isn't a part of this tradition.

Choice D Reason:
Dressing the client in a special amulet provided by the family is inappropriate. The use of amulets or charms isn't typically part of Islamic postmortem rituals. Islamic customs emphasize modesty in dress and following specific rites for the deceased, but incorporating special amulets or charms isn't a common practice.

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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?

Nursing Test Bank

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Explanation

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Explanation

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