You are working on the cardiac unit and you have noticed that a patient’s potassium is 6.1 mEq/L. You have notified the provider and removed the banana from his meal tray. When explaining your actions to the patient, which of these statements is appropriate?
Your potassium levels in your blood are higher than they should be, which brings a risk of changes in kidney function.
The amount of potassium in your blood is too high, but I will change your intravenous fluids.
Your potassium level is high so I need you to let me know if you feel numbness, tingling, or weakness.
I need to monitor you for signs of high potassium; tell me if you feel as if your heart is beating quickly.
The Correct Answer is C
Choice A reason: Linking high potassium to kidney function risk is inaccurate; hyperkalemia primarily affects cardiac and neuromuscular function. Numbness, tingling, or weakness are direct symptoms, making this statement less relevant for patient education and incorrect.
Choice B reason: Changing IV fluids may be a treatment but doesn’t explain the issue or engage the patient. Asking to report numbness, tingling, or weakness directly addresses hyperkalemia symptoms, making this less appropriate and incorrect.
Choice C reason: High potassium (6.1 mEq/L) can cause numbness, tingling, or weakness. Instructing the patient to report these symptoms ensures early detection of worsening hyperkalemia, making this the correct, patient-centered statement for education.
Choice D reason: Palpitations may occur, but numbness, tingling, and weakness are more specific to hyperkalemia’s neuromuscular effects. “Quick beating” is less precise for heart rhythm issues, so this is incorrect compared to option c.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Inward-pointing feet, or pigeon-toed appearance, describe intoeing, often due to metatarsus adductus or tibial torsion. Genu varum involves the knees angling outward, causing a bowed leg appearance, not foot positioning, making this an incorrect description.
Choice B reason: Genu varum, or bowlegs, is characterized by knees angling outward, creating a bowed appearance of the legs. This condition, common in toddlers or due to conditions like rickets, matches the described deformity, making this the correct description.
Choice C reason: Knees angling inward, causing a knock-kneed appearance, describes genu valgum, not genu varum. These are opposite deformities, with genu varum involving outward knee angulation, making this an incorrect description of the condition.
Choice D reason: Hyperextension of the knee joint, causing excessive leg straightening, describes genu recurvatum, not genu varum. Genu varum involves lateral knee angulation, not hyperextension, making this an incorrect description of the condition.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Increased permeability and leakage occur at an injury site due to histamine and cytokine release, causing endothelial gaps. This allows plasma and immune cells to enter tissues, promoting inflammation and edema, making this a correct vascular change.
Choice B reason: Blood vessels initially constrict to limit bleeding, then dilate to increase blood flow, delivering immune cells and nutrients. This biphasic response (constriction followed by dilation) is a hallmark of acute injury, making this a correct vascular change.
Choice C reason: Pallor occurs from initial vasoconstriction, reducing blood flow, followed by swelling from increased permeability and fluid leakage. These are typical injury responses, reflecting vascular and tissue changes, making this a correct observation.
Choice D reason: “None of the above” is incorrect, as increased permeability, biphasic vessel response, and pallor with swelling are well-documented vascular changes at injury sites. These align with the inflammatory process, making this an invalid choice.
Choice E reason: Tightening of capillary endothelial junctions does not occur during acute injury. Junctions loosen due to inflammatory mediators, increasing permeability, not tightening, which would limit leakage, making this an incorrect vascular change.
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