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 B
Explanation
Choice A Reason:
"I'll need to sign a separate consent form first." This statement might indicate a misunderstanding of the process or a belief that signing an advance directive requires a separate consent form, which might not be accurate.
Choice B Reason:
“the opportunity to choose what kind of care I receive while I still can. "This statement reflects the understanding that advance directives allow individuals to make decisions about the type of care they wish to receive while they are still capable of expressing their preferences. Advance directives, such as a living will, enable individuals to outline their healthcare preferences in advance, especially in situations where they might not be able to communicate their wishes later due to illness or incapacity.
Choice C Reason:
“living will, there will be a 1-month delay before it is legally binding. “There typically isn't a standard delay before a living will becomes legally binding. Once the living will be properly completed and witnessed according to legal requirements, it becomes effective.
Choice D Reason:
“have my mind about the care I will receive once I sign my living will." The purpose of a living will be to express one's healthcare preferences in advance. While it's possible to update or change a living will if one's preferences change, signing a living will doesn't inherently mean one can easily alter care preferences once it's in place. Amendments or revocations might require specific legal steps.
Correct Answer is B
Explanation
Choice A Reason:
"He may need a feeding tube" is inappropriate response. Suggesting a feeding tube without further assessment or information might be premature and could cause unnecessary concern or anxiety for the son. It's essential to explore the situation more before proposing such an intervention.
Choice B Reason:
"Tell me more about what happens at mealtime” is appropriate response. This response encourages the son to provide further details about the situation, allowing the nurse to gather more information about the specific issues or challenges related to the client's eating habits. Understanding the circumstances around mealtime can help the nurse identify potential reasons for the lack of appetite or eating difficulties and offer more targeted guidance or solutions.
Choice C Reason:
"Why do you think he's not eating?" This response is inappropriate. While asking about the son's thoughts is valuable, this question might not directly address the situation at hand or provide immediate assistance or guidance to address the client's eating difficulties.
Choice D Reason:
"I'm sure it's nothing serious and his appetite will return soon” is inappropriate response. Offering reassurance without understanding the underlying cause may downplay a potentially concerning issue. It's crucial to investigate the reasons behind the lack of appetite before assuming it will resolve without further action.
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