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 D
Explanation
Cleanse from the innermost point outwards with a circular movement. This technique reduces the risk of contaminating the wound with bacteria from the surrounding skin.
Some possible explanations for the other choices are:
Choice A is wrong because hydrogen peroxide and betadine solution can damage healthy tissue and delay wound healing.
Choice B is wrong because cleansing the wound from the outer edges towards the center can introduce bacteria from the skin into the wound.
Choice C is wrong because using 4x4 gauze to the wound and surrounding skin three times can cause trauma and bleeding to the wound.
Normal ranges for pressure ulcer stages are:
- Stage I: A reddened, painful area on the skin that does not turn white when pressed.
- Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
- Stage III: The skin develops an open, sunken hole called a crater or ulcer. The tissue below the skin is damaged.
- Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.
Correct Answer is D
Explanation
The needle gauge size for subcutaneous injections should be between 25 and 31, depending on the patient’s size and the viscosity of the medication.
A smaller gauge number means a larger diameter needle, which can cause more pain and tissue damage.
Choice A is wrong because 8 is too large for subcutaneous injections and can cause bleeding and bruising.
Choice B is wrong because 20 is also too large for subcutaneous injections and can cause similar complications as choice A.
Choice C is wrong because 21 is still too large for subcutaneous injections and can cause discomfort and injury to the patient.
The needle length for subcutaneous injections should be between ½ inch and ⅝ inch, depending on the amount of subcutaneous tissue present. The nurse should pinch the skin and insert the needle at a 45-degree angle to ensure proper delivery of the medication.
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