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","B","C"]
Explanation
Choice A reason: Subcutaneous administration of anticoagulants like Lovenox (enoxaparin) or heparin is a common and effective method for preventing DVT and VTE. These medications help prevent clot formation by thinning the blood and reducing the risk of thrombus development.
Choice B reason: Graduated compression stockings, such as thromboembolic deterrent (TED) hose, are used to improve blood flow in the legs and prevent the formation of blood clots. They apply consistent pressure to the legs, helping to maintain venous return and reduce the risk of DVT.
Choice C reason: Intermittent pneumatic compression devices (IPCs) are also used to prevent DVT and VTE. These devices periodically inflate and deflate, applying pressure to the legs to stimulate blood flow and prevent blood stasis, which can lead to clot formation.
Choice D reason: Strict bed rest is not recommended for DVT and VTE prevention. Prolonged immobility can increase the risk of clot formation. Encouraging early mobilization and activity is crucial to reduce the risk of DVT.
Choice E reason: Early and aggressive mobilization is a key strategy in preventing DVT and VTE. Encouraging patients to move and engage in physical activity as soon as it is safe to do so helps promote blood circulation and prevent the development of blood clots.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Respiratory status is crucial to monitor because patients with acute neurological deficits, such as those seen in strokes, are at risk of respiratory compromise. This can be due to weakened respiratory muscles or aspiration, which could lead to pneumonia or other respiratory complications.
Choice B reason: Monitoring liver enzymes is not directly related to the acute management of a stroke patient. Liver enzymes would be more relevant in cases where liver function or hepatic issues are suspected, but not for this specific scenario.
Choice C reason: Blood pressure monitoring is vital, as hypertension is a significant risk factor for stroke. Maintaining appropriate blood pressure is essential to prevent further neurological damage and complications. Acute changes in blood pressure can indicate worsening or improvement of the patient's condition.
Choice D reason: Neurological status should be continuously monitored to assess the progression of the patient's stroke symptoms. This includes checking for changes in level of consciousness, motor function, speech, and other neurological signs. Prompt detection of changes can guide immediate interventions.
Choice E reason: Potassium level monitoring is not a primary focus in the acute management of stroke. While electrolyte balance is important, it is not as critical as respiratory status, blood pressure, and neurological status in this context.
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