Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has diarrhea. Which of the following findings is a manifestation of hypokalemia?
A. Hypertension
None
B. Muscle weakness
Hypokalemia refers to low levels of potassium in the blood. Potassium is an essential electrolyte that plays a crucial role in nerve and muscle cell functioning. When potassium levels are low, it can lead to muscle weakness or even muscle cramps. Hypertension (high blood pressure) is not commonly associated with hypokalemia. In fact, hypokalemia can sometimes cause low blood pressure (hypotension). Hyperactive bowel sounds are more commonly associated with conditions such as diarrhea, gastroenteritis, or bowel obstruction. While diarrhea can contribute to electrolyte imbalances, it is not a specific manifestation of hypokalemia. Cerebral edema refers to swelling in the brain and is not typically associated with hypokalemia. Hypokalemia is more likely to affect muscle and nerve function rather than cerebral edema.
C. Hyperactive bowel sounds
None
D. Cerebral edema
None
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med surg exam 1A Proctored Exam. Take the full exam now
Full Explanation
Hypokalemia refers to low levels of potassium in the blood. Potassium is an essential electrolyte that plays a crucial role in nerve and muscle cell functioning. When potassium levels are low, it can lead to muscle weakness or even muscle cramps.
Hypertension (high blood pressure) is not commonly associated with hypokalemia. In fact, hypokalemia can sometimes cause low blood pressure (hypotension).
Hyperactive bowel sounds are more commonly associated with conditions such as diarrhea, gastroenteritis, or bowel obstruction. While diarrhea can contribute to electrolyte imbalances, it is not a specific manifestation of hypokalemia.
Cerebral edema refers to swelling in the brain and is not typically associated with hypokalemia. Hypokalemia is more likely to affect muscle and nerve function rather than cerebral edema.
Similar Questions
A nurse is caring for a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?
A. Hypokalemia
B. Hypercalcemia
C. Hypovolemia
D. Hyperglycemia
Dextrose 10% in water is a solution that contains glucose (a form of sugar) at a concentration of 10%. When infused into the bloodstream, it provides a source of carbohydrates for the body. However, it can also lead to an increase in blood glucose levels, resulting in hyperglycemia. Hyperglycemia refers to high blood glucose levels, which can cause a range of symptoms and complications, particularly in individuals who are unable to adequately regulate their blood sugar levels, such as those with diabetes. Symptoms of hyperglycemia may include increased thirst, frequent urination, fatigue, blurred vision, and, in severe cases, ketoacidosis. Hypokalemia refers to low levels of potassium in the blood and is not directly related to the administration of dextrose 10% in water. Hypercalcemia refers to high levels of calcium in the blood and is not associated with the administration of dextrose 10% in water. Hypovolemia refers to low blood volume and is not typically caused by the administration of dextrose 10% in water.
A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which of the following actions should the nurse take?
A. Administer each unit over 3 hr.
Administering packed red blood cells (PRBCs) over a specific timeframe is a crucial aspect of transfusion therapy. While the ideal duration for administering 1 unit of PRBCs is typically 2-4 hours, the specific rate depends on the client's condition, healthcare provider's orders, and institutional protocols. In certain situations, especially for older adult clients who may be more sensitive to rapid transfusions, administering each unit over a longer period (such as 3 hours) can help reduce the risk of adverse reactions, such as transfusion-related lung injury (TRALI) or fluid overload. Slower transfusion rates are often recommended for clients at higher risk of complications.
B. Use an 18-gauge needle to obtain venous access.
The gauge of the needle used for venous access during PRBC transfusions is an important consideration. However, using an 18-gauge needle, which is larger in diameter, may not be necessary for most clients and can cause discomfort or vein damage, particularly in older adults with fragile veins. A smaller gauge needle, such as 20-22 gauge, is usually sufficient for venous access and reduces the risk of complications such as infiltration or phlebitis.
C. Obtain the client's vital signs every 30 min throughout the transfusion.
Monitoring the client's vital signs, including temperature, blood pressure, pulse rate, and respiratory rate, at regular intervals during the transfusion is a standard and essential practice. This allows for early detection of transfusion reactions, hemolytic reactions, or other complications that may arise during the transfusion process. Monitoring every 30 minutes is a guideline commonly followed to ensure client safety.
D. Use blood that is less than a month old.
The age of blood used for transfusions is a critical factor in maintaining its efficacy and reducing the risk of adverse reactions. Fresh blood (less than a month old) is preferable, but the acceptable age of blood can vary depending on institutional policies and guidelines. While using fresher blood is ideal, blood that is up to 42 days old is generally considered acceptable for transfusion in many healthcare settings.
A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?
A. Decreased urine specific gravity
In fluid volume deficit, urine becomes more concentrated due to decreased kidney perfusion and water conservation by the body. This results in an increased urine specific gravity.
B. Decreased Hgb
Fluid volume deficit typically leads to hemoconcentration because there is less plasma volume, which makes hemoglobin and hematocrit levels appear elevated.
C. Increased urine ketones
While increased urine ketones may occur in dehydration associated with starvation or diabetic ketoacidosis (DKA), it is not a hallmark finding in general fluid volume deficit. The presence of ketones depends on the underlying cause, not on fluid volume status alone.
D. Increased BUN
Blood urea nitrogen (BUN) increases in fluid volume deficit because of hemoconcentration and reduced kidney perfusion, which slows the excretion of urea. The ratio of BUN to creatinine is often elevated in dehydration (>20:1).
Full Explanation
A. Decreased urine specific gravity: In fluid volume deficit, urine becomes more concentrated due to decreased kidney perfusion and water conservation by the body. This results in an increased urine specific gravity.
B. Decreased Hgb: Fluid volume deficit typically leads to hemoconcentration because there is less plasma volume, which makes hemoglobin and hematocrit levels appear elevated.
C. Increased urine ketones: While increased urine ketones may occur in dehydration associated with starvation or diabetic ketoacidosis (DKA), it is not a hallmark finding in general fluid volume deficit. The presence of ketones depends on the underlying cause, not on fluid volume status alone.
D. Increased BUN: Blood urea nitrogen (BUN) increases in fluid volume deficit because of hemoconcentration and reduced kidney perfusion, which slows the excretion of urea. The ratio of BUN to creatinine is often elevated in dehydration (>20:1).