Which electrolyte imbalance should a nurse expect to assess in a client who reports diarrhea for the past three days?
Hypokalemia.
Hypocalcemia.
Hyponatremia.
Hypochloremia.
The Correct Answer is A
This is because diarrhea can cause a loss of potassium along with water and other electrolytes. Potassium is an important mineral that helps regulate the heartbeat, nerve impulses and muscle contractions. Low levels of potassium can cause symptoms such as weakness, fatigue, muscle cramps, irregular heartbeat and constipation.
Choice B. Hypocalcemia is wrong because diarrhea does not usually cause a loss of
calcium. Calcium is another mineral that helps with muscle and nerve function, blood clotting and bone health. Low levels of calcium can cause symptoms such as numbness, tingling, muscle spasms, seizures and confusion.
Choice C. Hyponatremia is wrong because diarrhea can cause a loss of sodium, but not to the extent that it causes hyponatremia. Sodium is the most abundant electrolyte in the body and it helps regulate fluid balance, blood pressure and nerve and muscle function. Low levels of sodium can cause symptoms such as headache, confusion, nausea, vomiting, seizures and coma.
Choice D. Hypochloremia is wrong because diarrhea can cause a loss of chloride, but not to the extent that it causes hypochloremia. Chloride is another electrolyte that helps maintain fluid balance, blood pressure and acid-base balance. Low levels of chloride can cause symptoms such as weakness, dehydration, alkalosis (high blood pH) and muscle twitching.
The normal ranges for electrolytes in the blood are:
- Potassium: 3.5 to 5 mEq/L
- Calcium: 8.5 to 10.2 mg/dL
- Sodium: 135 to 145 mEq/L
- Chloride: 96 to 106
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
The nurse should use clarifying points made by the patient that are unclear and listening attentively while speaking slowly and clearly as communication techniques when performing a health history.
These techniques help the nurse to gather accurate and comprehensive information from the patient and to establish rapport and trust.
Choice A is wrong because avoiding silences can make the patient feel rushed or interrupted. Silences can be useful to allow the patient to think or express emotions.
Choice D is wrong because sitting approximately two feet away from the client may be too close and invade the personal space of the client. The nurse should maintain a comfortable distance of about 4 to 5 feet from the client, depending on the cultural norms and preferences of the client.
Choice E is wrong because asking the family member to complete the written form may not reflect the true health history of the client. The nurse should obtain the information directly from the client whenever possible, unless the client is unable or unwilling to provide it.
Correct Answer is A
Explanation
A two-day postoperative client who has a large abdominal incision and says, “Something feels like it just popped open after I practiced my coughing”. This client may have a dehiscence or separation of the surgical wound, which is a serious complication that requires immediate attention.
The nurse should evaluate this client first and notify the surgeon.
Choice B is wrong because bile-colored fluid draining from a nasogastric tube is an expected finding after abdominal surgery and does not indicate an urgent problem.
The nurse should monitor the client’s fluid and electrolyte balance and provide antiemetics as needed.
Choice C is wrong because a three-day postoperative client who has an ileostomy and reports the need to have a bowel movement may have a paralytic ileus or a temporary cessation of bowel motility. This is a common postoperative complication that usually resolves within 72 hours.
The nurse should assess the client’s bowel sounds, abdominal distension, and ostomy output and encourage early mobilization and oral intake as tolerated.
Choice D is wrong because a three-day postoperative client who is receiving intravenous antibiotics for a wound infection may have a surgical site infection or an infection that occurs within 30 days of surgery. This is a preventable complication that can be managed with antibiotics, wound care, and infection control measures.
The nurse should monitor the client’s vital signs, wound appearance, and laboratory values and educate the client on signs and symptoms of infection.
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