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 ["A","C"]
Explanation
Choice A reason: Offering high-calorie protein snacks between meals and at bedtime is appropriate for a patient with COPD who is losing weight and eating very little. These snacks can help meet their nutritional needs and provide the extra calories and protein necessary to prevent muscle wasting and support overall health.
Choice B reason: While increasing the intake of whole grains and vegetables is generally healthy, it may not be the priority for a patient who has lost significant weight and needs to focus on higher-calorie, nutrient-dense foods. The primary goal is to address the calorie and protein deficit first.
Choice C reason: Encouraging rest before meals is beneficial as it helps conserve energy for eating. Patients with COPD often experience fatigue, which can reduce their appetite and ability to eat. Resting before meals can help them feel more energetic and better able to consume their meals.
Choice D reason: Providing a large glass of juice with each meal is not ideal for increasing calorie and protein intake. While juice can provide some calories and nutrients, it is not a good source of protein. Additionally, large volumes of liquid can create a feeling of fullness, reducing the patient's appetite for nutrient-dense foods.
Correct Answer is C
Explanation
Choice A reason: While blood glucose monitoring is essential for patients receiving TPN, it is not specifically necessary to obtain samples from a central line. Blood glucose levels can be monitored through peripheral blood samples.
Choice B reason: There is actually an increased risk of infection with central lines compared to peripheral lines due to the invasive nature of central line placement and its location. Proper aseptic technique is critical to minimize this risk.
Choice C reason: The hypertonic solution will be more rapidly diluted when given through a central line. This is a critical point because the central veins have a higher blood flow and larger volume, which helps to quickly dilute the hypertonic TPN solution. This reduces the risk of phlebitis and damage to the smaller peripheral veins, making central lines more suitable for infusing highly concentrated solutions like 25% dextrose.
Choice D reason: While a central line can allow for the rapid administration of infusions, this is not the primary reason for its use with TPN. The key factor is the dilution of the hypertonic solution, as central lines handle high osmolarity solutions better than peripheral veins.
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