The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching?

optic function

cardiac function

auditory function

skeletal function

Answer and Explanation

The Correct Answer is B

A. Optic function: While potassium plays a role in cellular processes, including those in the eyes, its primary effects are felt in areas like the cardiovascular system. The optic nerve and visual processing are not influenced by potassium levels.

B. Cardiac function: Potassium is crucial for maintaining normal cardiac function. It helps regulate the electrical activity of the heart, and its imbalance can lead to arrhythmias, which can be life-threatening. Hypokalemia can cause disturbances in the heart’s rhythm, making it the most critical aspect to address.

C. Auditory function: Potassium levels do not affect auditory function. Potassium is involved in bodily functions, including maintaining the electrochemical gradients necessary for nerve and muscle activity, but it does not have a role in hearing or auditory processes.

D. Skeletal function: Potassium is important for muscle function, including skeletal muscles. Potassium’s role in muscle contraction extends to both skeletal and smooth muscles, but its impact on the heart’s electrical system makes cardiac function the priority.

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Correct Answer is C

Explanation

A. Ask another nurse to verify the pulse rate: While verification can be helpful in some situations, it is not the first step in interpreting an abnormal vital sign.

B. Notify the client's health care provider: Immediate notification is appropriate if the pulse rate is critically abnormal and the client is symptomatic. However, assessment and analysis should precede notification.

C. Compare the client's pulse rate to the standard range and trends: The nurse should first analyze the pulse rate in the context of normal ranges (60–100 bpm for adults) and assess any changes or patterns over time to determine clinical significance.

D. Document the pulse in the appropriate chart page: Documentation is necessary but should occur after the nurse has interpreted and assessed the vital sign for possible interventions. Interpretation is a critical part of the nursing process that directly influences further decisions.

A. If connected to suction, do not reconnect to suction for 5 minutes after drug administration. B. Administer the medication at a cold temperature C. Position the client supine prior to administering the drug D. Flush the tube with water between each drug administered

Correct Answer is D

Explanation

A. If connected to suction, do not reconnect to suction for 5 minutes after drug administration: The nurse should actually clamp or disconnect suction during and for at least 30 minutes after administration to allow absorption, so 5 minutes is insufficient.

B. Administer the medication at a cold temperature: Medications should be administered at room temperature to prevent gastric discomfort or cramping. Cold medications can cause nausea or spasms.

C. Position the client supine prior to administering the drug: The client should be positioned upright or with the head of the bed elevated (at least 30–45 degrees) to reduce risk of aspiration during administration.

D. Flush the tube with water between each drug administered: Flushing the nasogastric tube with water before, between, and after medications prevents clogging and ensures proper delivery of each drug and helps prevent drug incompatibilities.

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The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse takes a client's vital signs and finds the pulse rate to be 120 bpm. What would the nurse do next to interpret and analyze this pulse rate?

Correct Answer is C

Explanation

The nurse is preparing to administer a medication via a nasogastric tube. Which guideline is appropriate for the nurse to follow when administering a drug via this route?

Correct Answer is D

Explanation

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