what should the nurse monitor for in a patient with hypokalemia

ATI RN

ATI Capstone Adult Medical Surgical Assessment 2

1. What should the nurse monitor for in a patient with hypokalemia?

A. Monitor for muscle weakness
B. Check deep tendon reflexes (DTRs)
C. Monitor for seizures
D. Monitor for bradycardia

Correct answer: A

Rationale: The correct answer is to monitor for muscle weakness in a patient with hypokalemia. Hypokalemia, which is low potassium levels, can lead to muscle weakness due to its effects on neuromuscular function. Checking deep tendon reflexes (Choice B) is not typically associated with hypokalemia. Seizures (Choice C) are more commonly associated with low calcium levels rather than low potassium levels. Bradycardia (Choice D) is a symptom of hyperkalemia (high potassium levels) rather than hypokalemia.

2. What are the expected changes on an ECG for a patient with hypokalemia?

A. Flattened T waves
B. Prominent U waves
C. ST elevation
D. Wide QRS complexes

Correct answer: A

Rationale: Flattened T waves are an early sign of hypokalemia on an ECG. Hypokalemia primarily manifests as flattened T waves on an ECG. While prominent U waves can be seen in hypokalemia, they are not as specific as flattened T waves. ST elevation is more commonly associated with conditions like myocardial infarction rather than hypokalemia. Wide QRS complexes are typically not a feature of hypokalemia on an ECG.

3. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

A. Axillary temperature 37.2°C (99°F)
B. Apical pulse 100/min
C. Respiratory rate 30/min
D. Blood pressure 140/84 mm Hg

Correct answer: C

Rationale: The correct answer is C. The nurse should prioritize airway and breathing in a client with a traumatic brain injury. An increased respiratory rate may indicate CO2 retention, which could lead to increased intracranial pressure. Choice A, axillary temperature 37.2°C (99°F), is within normal range and does not indicate an immediate need for intervention. Choice B, apical pulse 100/min, is slightly elevated but not as critical as respiratory distress in this scenario. Choice D, blood pressure 140/84 mm Hg, is also within normal limits and does not require immediate intervention compared to the respiratory rate.

4. What teaching should be provided after cataract surgery?

A. Avoid NSAIDs
B. Wear dark glasses outdoors
C. Creamy white drainage is normal
D. Avoid bright lights

Correct answer: A

Rationale: The correct teaching that should be provided after cataract surgery is to avoid NSAIDs. NSAIDs should be avoided to prevent bleeding, especially in the eye area. While wearing dark glasses outdoors is important to protect the eyes, it is not the most critical teaching after cataract surgery. Creamy white drainage being normal is not relevant to post-cataract surgery teaching. Avoiding bright lights is generally recommended for patients with certain eye conditions but is not a specific teaching point after cataract surgery.

5. What should be monitored for in a patient with compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Localized redness and swelling
C. Fever and infection
D. Muscle weakness and fatigue

Correct answer: A

Rationale: Correct Answer: A. Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome that indicate inadequate blood flow to the affected area. These symptoms are crucial to monitor as they signify a medical emergency requiring immediate intervention. Choices B, C, and D are incorrect because they do not align with the typical manifestations of compartment syndrome. Localized redness and swelling may be present but are not the primary indicators. Fever and infection are also not specific to compartment syndrome, and muscle weakness and fatigue are not typically prominent symptoms of this condition.