Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?
A. Hypokalemia.
Hypokalemia refers to a lower-than-normal level of potassium in the bloodstream. Normal potassium levels are typically between 3.5 and 5.0 mEq/L. In the context of nephrotic syndrome and high-dose corticosteroid therapy, hypokalemia can occur due to increased urinary potassium losses caused by corticosteroid-induced alterations in kidney function. Corticosteroids can promote the excretion of potassium, leading to a deficiency.
B. Hypomagnesemia.
Hypomagnesemia is a condition where there is a magnesium deficiency in the blood, with normal levels usually ranging between 1.7 and 2.2 mg/dL. While it can occur in nephrotic syndrome due to urinary losses of proteins that bind magnesium, it is not typically associated with corticosteroid therapy. Therefore, it is less likely to be monitored in this specific scenario.
C. Hypermagnesemia.
Hypermagnesemia indicates an abnormally high level of magnesium in the blood. This condition is relatively rare and is not commonly associated with nephrotic syndrome or corticosteroid therapy. It is more often related to renal failure or excessive intake of magnesium-containing medications or supplements.
D. Hyperkalemia.
Hyperkalemia is characterized by an elevated level of potassium in the blood, with normal levels being 3.5 to 5.0 mEq/L. While hyperkalemia can occur in nephrotic syndrome due to the loss of albumin in the urine, which can affect calcium and potassium binding, corticosteroid therapy typically causes a decrease in potassium levels, making hypokalemia a more relevant concern in this context.
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Full Explanation
The correct answer is: A
Choice A Reason: Hypokalemia refers to a lower-than-normal level of potassium in the bloodstream. Normal potassium levels are typically between 3.5 and 5.0 mEq/L. In the context of nephrotic syndrome and high-dose corticosteroid therapy, hypokalemia can occur due to increased urinary potassium losses caused by corticosteroid-induced alterations in kidney function. Corticosteroids can promote the excretion of potassium, leading to a deficiency.
Choice B Reason: Hypomagnesemia is a condition where there is a magnesium deficiency in the blood, with normal levels usually ranging between 1.7 and 2.2 mg/dL. While it can occur in nephrotic syndrome due to urinary losses of proteins that bind magnesium, it is not typically associated with corticosteroid therapy. Therefore, it is less likely to be monitored in this specific scenario.
Choice C Reason: Hypermagnesemia indicates an abnormally high level of magnesium in the blood. This condition is relatively rare and is not commonly associated with nephrotic syndrome or corticosteroid therapy. It is more often related to renal failure or excessive intake of magnesium-containing medications or supplements.
Choice D Reason: Hyperkalemia is characterized by an elevated level of potassium in the blood, with normal levels being 3.5 to 5.0 mEq/L. While hyperkalemia can occur in nephrotic syndrome due to the loss of albumin in the urine, which can affect calcium and potassium binding, corticosteroid therapy typically causes a decrease in potassium levels, making hypokalemia a more relevant concern in this context.
Similar Questions
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
A. Restlessness.
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
B. Tachycardia.
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
C. Hypotension.
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
D. Amnesia.
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
Full Explanation
Choice A rationale:
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
Choice B rationale:
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
Choice C rationale:
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
Choice D rationale:
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
A. Restlessness.
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
B. Tachycardia.
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
C. Hypotension.
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
D. Amnesia.
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
Full Explanation
Choice A rationale:
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
Choice B rationale:
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
Choice C rationale:
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
Choice D rationale:
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy.
The client's spouse asks the nurse what the procedure entails.
Which of the following nursing statements is appropriate?
A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.”.
This statement describes a skin graft, not an escharotomy.
B. "Large incisions will be made in the eschar to improve circulation.”.
An escharotomy involves making large incisions in the eschar (burned tissue) to relieve pressure and improve circulation to the area.
C. "Dead tissue will be non-surgically removed.”.
This statement describes debridement, which is the removal of dead tissue, but it is not specific to an escharotomy.
D. "This procedure involves placing the client into a shower and removing the dead tissue.”.
This statement describes a method of debridement, not an escharotomy.
Full Explanation
Choice A rationale:
This statement describes a skin graft, not an escharotomy.
Choice B rationale:
An escharotomy involves making large incisions in the eschar (burned tissue) to relieve pressure and improve circulation to the area.
Choice C rationale:
This statement describes debridement, which is the removal of dead tissue, but it is not specific to an escharotomy.
Choice D rationale:
This statement describes a method of debridement, not an escharotomy.