What type of electrolyte imbalance would most likely occur following the administration of three tap water enemas?
Hypokalemia
Hypocalcemia
Hypernatremia
Hyperphosphatemia
The Correct Answer is A
A. Hypokalemia: Tap water enemas can cause excessive fluid shifts, leading to potassium loss via stool and dilutional effects. Multiple enemas can result in hypokalemia (low K⁺), which may cause muscle weakness and cardiac arrhythmias.
B. Hypocalcemia: Tap water enemas do not significantly affect calcium levels.
C. Hypernatremia: Tap water is hypotonic, leading to fluid absorption rather than sodium excess.
D. Hyperphosphatemia: Enemas can cause hypophosphatemia rather than excess phosphate levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Provide water for a client diagnosed with chronic kidney disease: Fluid intake must be controlled in CKD. A nurse should determine if water intake is appropriate.
B. Instruct the client on appropriate fluid restrictions: Client education is a nursing responsibility and cannot be delegated to a UAP. The nurse should educate clients on fluid restrictions in conditions like chronic kidney disease (CKD) to prevent fluid overload and electrolyte imbalances.
C. Measure the client’s output from the indwelling catheter: This task can be delegated to a UAP.
D. Record the client’s intake and output in the EMR: UAPs can record I&O but cannot interpret the data.
Correct Answer is A
Explanation
A. Oliguria: Reduced urine output (oliguria) can indicate acute rejection due to decreased renal function. Other signs include fever, hypertension, graft tenderness, and swelling.
B. Temperature 36.1° C (97.0° F): Rejection often causes fever, not a low temperature.
C. Weight loss: Weight gain (fluid retention) is more common with rejection.
D. Insomnia: Insomnia is not a direct sign of rejection.
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