The nurse is obtaining the intershift report for a group of ...

[SAVANNAHHOOPER23]

The nurse is obtaining the intershift report for a group of assigned clients. Which of the following assigned clients should the nurse monitor closely for signs of hyperkalemia?
 
  1. A client with ulcerative colitis
  2. A client with Cushing's syndrome
  3. A client admitted 6 hours ago with a 40 burn injury
  4. A client who has a history of long-term laxative abuse

Question 2

A nursing student is assigned to care for a child following surgery to correct cryptorchidism.
 
  The nursing instructor reviews the plan of care developed by the student and determines that the stu-dent is adequately prepared to care for the child if the student identifies which priority in the plan of care following this type of surgery? 1. Prevent tension on the suture.
  2. Force oral fluids, and monitor I&O.
  3. Monitor urine for glucose and acetone.
  4. Encourage coughing and deep breathing every hour.

[jlaineee]

Answer to Question 1

3

Rationale: Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome, ulcerative colitis, or those using laxatives excessively are at risk for hypokalemia.

Answer to Question 2

1

Rationale: When a child returns from surgery, the testicle is held in position by an internal suture that passes through the testes and scrotum and is attached to the thigh. It is important not to dislodge this suture, and it should be immobilized for 1 week. The most common complications are bleeding and infection. Depending on the type of anesthesia used, encourage coughing and deep breathing every hour may be appropriate, but it is not the priority. Although it is important to maintain adequate hydration, it is inappropriate and unnecessary to force fluids. Testing urine for glucose and acetone also is not related to surgery.

[SAVANNAHHOOPER23]

Excellent

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TYSM