A patient who is taking a potassium-wasting diuretic for the treatment of hypertension reports generalized weakness. Which action is appropriate for the nurse to take?
Ask the patient about loose stools
Suggest that the healthcare provider order a basic metabolic panel
Assess for facial muscle spasms
Call for a rapid response team
The Correct Answer is B
Choice A reason: Asking the patient about loose stools is important as it can help identify possible causes of fluid and electrolyte imbalances. However, this question alone would not be the immediate or primary action to take in response to generalized weakness.
Choice B reason: Suggesting that the healthcare provider order a basic metabolic panel is the most appropriate action. Potassium-wasting diuretics can lead to hypokalemia, which can cause symptoms like generalized weakness. A basic metabolic panel will provide information on the patient's electrolyte levels, including potassium, and help determine if the weakness is due to an electrolyte imbalance. This allows for appropriate intervention to correct the imbalance and prevent further complications.
Choice C reason: Assessing for facial muscle spasms is relevant because hypokalemia can cause muscle cramps and spasms. However, it does not address the root cause of the weakness and does not lead to immediate intervention.
Choice D reason: Calling for a rapid response team is generally reserved for situations where the patient is experiencing acute, life-threatening symptoms requiring immediate intervention. Generalized weakness in the context of a patient on a potassium-wasting diuretic does not usually necessitate such an urgent response unless it progresses to more severe symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Endocardial infection is not commonly associated with Alzheimer's disease. While it can occur, it is not a frequent infection related to chronic dementia.
Choice B reason: Brain infections, such as encephalitis, can occur but are not among the most common infections seen in patients with Alzheimer's disease.
Choice C reason: Urinary tract infections (UTIs) are common in patients with Alzheimer's disease due to factors such as immobility, incontinence, and the use of catheters. UTIs can exacerbate confusion and other dementia-related symptoms.
Choice D reason: Pneumonia is a common and serious infection in patients with Alzheimer's disease. Due to cognitive impairment, these patients may have difficulty swallowing, leading to aspiration pneumonia. Additionally, their weakened immune systems make them more susceptible to respiratory infections.
Choice E reason: Gastrointestinal infections are not typically associated with Alzheimer's disease as a common complication. While they can occur, they are not as prevalent as UTIs and pneumonia in this patient population.
Correct Answer is ["B","D","C"]
Explanation
Choice A reason: Shivering can be a response to various conditions, including cold temperatures or fever, but it is not a direct indicator to discontinue suctioning. While it may be concerning, it does not specifically suggest a problem caused by the suctioning procedure.
Choice B reason: Decreased SpO₂ (oxygen saturation) is a critical sign that the patient is not getting enough oxygen. This condition requires immediate attention, and suctioning should be stopped to assess and address the cause of the hypoxia. Continuing to suction can exacerbate respiratory distress and further lower oxygen levels.
Choice C reason: Absence of coughing is a sign that the patient's airway may be compromised or that the suctioning is too aggressive, potentially leading to further complications. Coughing is a protective reflex that helps clear the airway, and its absence indicates that the airway is not adequately protected, warranting cessation of suctioning.
Choice D reason: Development of dysrhythmias (irregular heartbeats) during suctioning is a serious concern. Dysrhythmias can indicate that the patient is experiencing significant physiological stress or that the vagus nerve is being stimulated, which can impact heart function. Immediate discontinuation of suctioning is necessary to prevent cardiac complications and to stabilize the patient's condition.
Choice E reason: Increased blood pressure, while indicative of stress or pain, is not an immediate indicator to stop suctioning. It should be monitored and addressed, but it does not pose the same immediate risk as decreased oxygen saturation or dysrhythmias.
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