Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an urgent care clinic is collecting data from a client who reports having diarrhea for the past 3 days. Which of the following findings indicates hypokalemia?
A. Pitting edema
Pitting edema is not a typical symptom of hypokalemia
B. Diplopia
Diplopiais not a typical symptom of hypokalemia.
C. Muscle weakness
A nurse collecting data from a client who reports having diarrhea for the past 3 days should identify that muscle weakness is a symptom of hypokalemia. Hypokalemia is a condition in which the blood potassium level is low and can be caused by excessive fluid loss through diarrhea. Potassium helps regulate muscle contractions, so when blood potassium levels are low, muscles may produce weaker contractions which result in muscle weakness.
D. Hyperactive bowel sounds
Hyperactive bowel soundsare not a typical symptom of hypokalemia.
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
A nurse collecting data from a client who reports having diarrhea for the past 3 days should identify that muscle weakness is a symptom of hypokalemia. Hypokalemia is a condition in which the blood potassium level is low and can be caused by excessive fluid loss through diarrhea. Potassium helps regulate muscle contractions, so when blood potassium levels are low, muscles may produce weaker contractions which result in muscle weakness.
The other options are not typical symptoms of hypokalemia.
a) Pitting edema is not a typical symptom of hypokalemia.
b) Diplopia is not a typical symptom of hypokalemia.
d) Hyperactive bowel sounds are not a typical symptom of hypokalemia.
Similar Questions
A nurse is reviewing the laboratory results of a client who has DKA. The client's ABG results are pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L. The nurse should identify that these values indicate which of the following acid-base imbalances?
A. Respiratory alkalosis
Respiratory alkalosis is an acid-base imbalance characterized by a high pH (greater than 7.45) and a low PaCO₂ (less than 35 mm Hg).
B. Metabolic alkalosis
Metabolic alkalosisis an acid-base imbalance characterized by a high pH (greater than 7.45) and a high bicarbonate level (greater than 26 mEq/L).
C. Metabolic acidosis
A nurse reviewing the laboratory results of a client who has DKA should identify that the client's ABG results of pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L indicate metabolic acidosis. Metabolic acidosis is an acid-base imbalance characterized by a low pH (less than 7.35) and a low bicarbonate level (less than 22 mEq/L).
D. Respiratory acidosis
Respiratory acidosis is an acid-base imbalance characterized by a low pH (less than 7.35) and a high PaCO₂ (greater than 45 mm Hg).
Full Explanation
A nurse reviewing the laboratory results of a client who has DKA should identify that the client's ABG results of pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L indicate metabolic acidosis. Metabolic acidosis is an acid-base imbalance characterized by a low pH (less than 7.35) and a low bicarbonate level (less than 22 mEq/L).
The other options are not correct.
a) Respiratory alkalosis is an acid-base imbalance characterized by a high pH (greater than 7.45) and a low PaCO₂ (less than 35 mm Hg).
b) Metabolic alkalosis is an acid-base imbalance characterized by a high pH (greater than 7.45) and a high bicarbonate level (greater than 26 mEq/L).
d) Respiratory acidosis is an acid-base imbalance characterized by a low pH (less than 7.35) and a high PaCO₂ (greater than 45 mm Hg).
A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse should recognize that the client needs a referral for diabetic education when the client does which of the following?
A. Draws up regular insulin before NPH when demonstrating injection technique
Drawing up regular insulin before NPH when demonstrating injection technique is the correct procedure.
B. Says that he will see a primary care provider to treat corns on his feet
Seeing a primary care provider to treat corns on the feet is an appropriate action for a client with diabetes.
C. States that he will treat hypoglycemic reactions with 15 g of carbohydrates
Treating hypoglycemic reactions with 15 g of carbohydrates is the recommended treatment.
D. Lists sweating, shaking, and palpitations as symptoms of hyperglycemia
The nurse should recognize that the client needs a referral for diabetic education when the client lists sweating, shaking, and palpitations as symptoms of hyperglycemia. These symptoms are actually associated with hypoglycemia, not hyperglycemia. Hyperglycemia is characterized by symptoms such as increased thirst, frequent urination, and fatigue.
Full Explanation
The nurse should recognize that the client needs a referral for diabetic education when the client lists sweating, shaking, and palpitations as symptoms of hyperglycemia. These symptoms are actually associated with hypoglycemia, not hyperglycemia. Hyperglycemia is characterized by symptoms such as increased thirst, frequent urination, and fatigue.
Option a is incorrect because drawing up regular insulin before NPH when demonstrating injection technique is the correct procedure.
Option b is incorrect because seeing a primary care provider to treat corns on the feet is an appropriate action for a client with diabetes.
Option c is incorrect because treating hypoglycemic reactions with 15 g of carbohydrates is the recommended treatment.
A nurse is reviewing the medical record of a client who is requesting an oral contraceptive.
Which of the following findings should the nurse identify as a contraindication to the use of oral contraceptives?
A. History of renal calculus
Is not contraindications to the use of oral contraceptives.
B. Migraines with aura
Migraines with aura are considered a contraindication to the use of oral contraceptives. Auras are neurological symptoms that occur before or during migraines and can include visual disturbances, sensory changes, or speech difficulties. Women who experience migraines with aura have an increased risk of ischemic stroke when taking oral contraceptives. Therefore, it is important to identify this condition as a contraindication and explore alternative contraceptive options for the client.
C. BMI of 25
Is not contraindications to the use of oral contraceptives.
D. History of cholecystectomy
Is not contraindications to the use of oral contraceptives.
Full Explanation
b. Migraines with aura.
Explanation:
Migraines with aura are considered a contraindication to the use of oral contraceptives. Auras are neurological symptoms that occur before or during migraines and can include visual disturbances, sensory changes, or speech difficulties. Women who experience migraines with aura have an increased risk of ischemic stroke when taking oral contraceptives. Therefore, it is important to identify this condition as a contraindication and explore alternative contraceptive options for the client.
The other options (a. History of renal calculus, c. BMI of 25, d. History of cholecystectomy) are not contraindications to the use of oral contraceptives.
