A nurse is gathering data on a patient who has diarrhea.
Which of the following findings is a sign of hypokalemia?

Hypertension.

Cerebral edema.

Muscle weakness.

Hyperactive bowel sounds.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Hypertension is not typically a sign of hypokalemia. Hypokalemia, or low potassium levels, can cause symptoms like fatigue, muscle weakness, digestive problems, and frequent urination. Hypertension, or high blood pressure, is not commonly associated with hypokalemia.

Choice B rationale:

Cerebral edema, or swelling in the brain, is not a common symptom of hypokalemia. Hypokalemia is more likely to cause symptoms related to muscle function and digestion, as potassium is an essential mineral that helps regulate muscle contractions, maintain healthy nerve function, and regulate fluid balance.

Choice C rationale:

Muscle weakness is a common symptom of hypokalemia. Potassium helps regulate muscle contractions. When blood potassium levels are low, your muscles produce weaker contractions. This can result in symptoms like muscle weakness and fatigue.

Choice D rationale:

Hyperactive bowel sounds are not typically associated with hypokalemia. Hypokalemia can cause digestive problems, but these are more likely to be issues like constipation rather than increased bowel sounds.

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Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

The nurse applies the sterile drape after cleaning the perineal area. This is correct because the perineal area should be cleaned before applying the sterile drape. Applying the drape first could potentially introduce bacteria to the catheter during insertion, increasing the risk of a urinary tract infection.

Choice B rationale:

The nurse lubricates the indwelling urinary catheter. This is a correct procedure as it helps to minimize discomfort and trauma during catheter insertion.

Choice C rationale:

The nurse separates the patient’s labia with her dominant hand. This is also a correct procedure. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and then use her dominant hand to insert the catheter.

Choice D rationale:

The nurse provides perineal care prior to inserting the urinary catheter. This is a correct procedure. Providing perineal care before inserting a urinary catheter is important to reduce the risk of introducing bacteria into the urinary tract. It’s part of maintaining strict aseptic technique during insertion.

A. Place the patient on continuous cardiac monitoring. B. Obtain a prescription for insulin for the patient. C. Plan to administer sodium bicarbonate to the patient. D. Have the patient breathe into a paper bag.

Correct Answer is A

Explanation

Choice A rationale:

Metabolic alkalosis is an acid-base imbalance characterized by excessive loss of acid or excessive gain of bicarbonate produced by an underlying pathologic disorder. It causes metabolic, respiratory, and renal responses, producing characteristic symptoms. One of the manifestations of metabolic alkalosis is cardiovascular abnormalities, such as atrial tachycardia. Therefore, placing the patient on continuous cardiac monitoring is a necessary action to assess the patient’s heart rate and rhythm and detect any abnormalities early.

Choice B rationale:

Insulin is not typically used in the treatment of metabolic alkalosis. Insulin is a hormone that regulates blood sugar levels. It’s not directly related to the body’s acid-base balance. Therefore, obtaining a prescription for insulin for the patient would not be a relevant action in this case.

Choice C rationale:

Administering sodium bicarbonate to a patient with metabolic alkalosis would not be appropriate. Sodium bicarbonate is a base and is often used to treat metabolic acidosis, a condition characterized by an excess of acid in the body. Giving sodium bicarbonate to a patient with metabolic alkalosis, a condition characterized by an excess of base in the body, could potentially worsen the patient’s condition.

Choice D rationale:

Having the patient breathe into a paper bag is a common treatment for respiratory alkalosis, not metabolic alkalosis.

Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide in the blood. Breathing into a paper bag helps to increase the amount of carbon dioxide the person inhales, helping to restore the acid-base balance. However, metabolic alkalosis is not caused by hyperventilation, so this treatment

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A nurse is gathering data on a patient who has diarrhea. Which of the following findings is a sign of hypokalemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female patient. Which action by the nurse should prompt the charge nurse to intervene?

Correct Answer is C

Explanation

A nurse is caring for a patient with metabolic alkalosis. What actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a patient who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

A nurse is caring for a patient who is experiencing nausea and vomiting. The nurse should identify that the patient is at risk for which of the following acid-base imbalances?

A nurse is instructing a newly licensed nurse on how to obtain a fecal occult blood test from a patient. What information should the nurse include?

A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?

A nurse is in the process of collecting a urine specimen for culture and sensitivity through straight catheterization. Which step should the nurse take in this procedure?

A nurse is helping to implement a bowel training program for a patient. To ensure the effectiveness of the program, when should the nurse take the patient to the bathroom?

A nurse is providing dietary advice to a patient at risk for hypokalemia. Which food should the nurse recommend as a good source of potassium?

A nurse is collecting data on a client who has urinary retention. What findings should the nurse expect?

A nurse is gathering data on a patient who has diarrhea.
Which of the following findings is a sign of hypokalemia?