NR-324 Adult Health I - Set 1 - Part 3

Correct Answer: Ascending weakness with reduced reflexes

A high potassium first depolarizes the membrane and then inactivates sodium channels, so the cell can no longer fire. The result is ascending flaccid weakness with diminished or absent deep tendon reflexes rather than brisk ones. Option a is incorrect because sustained depolarization leaves muscle unexcitable, so reflexes fade instead of sharpening. The mnemonic many students memorise prints increased reflexes, and that line contradicts every sign list beside it. Option c is incorrect because spasm of the hand during cuff inflation is the Trousseau sign of a low calcium level. Calcium, not potassium, is the electrolyte that produces tetany of that kind. Option d is incorrect because an electrolyte acts on every excitable cell at once, producing symmetric findings. Weakness confined to one limb suggests a stroke or a nerve injury and would prompt a different workup.

Correct Answer: The pH is read first to fix the direction.

Step one uses the pH alone to decide whether the client is on the acid or alkaline side. Only after that direction is fixed do the carbon dioxide and bicarbonate identify the culprit. Option b is incorrect because starting with carbon dioxide is the habit that produces wrong answers on compensated gases. A raised level may be the primary problem or the lungs compensating. Option c is incorrect because the speed of renal handling has nothing to do with reading order. Bicarbonate is examined at step two alongside carbon dioxide, once the pH has chosen a side. Option d is incorrect because oxygenation belongs to the final step and forms no part of naming the disorder. It answers a separate clinical question, though often an extremely urgent one.

Correct Answer: A rising serum potassium level

In acidosis the abundant extracellular hydrogen moves into cells and potassium moves out to preserve electrical neutrality. The serum potassium therefore rises, which is why acidemia and hyperkalaemia appear together. Option a is incorrect because a falling potassium belongs to alkalosis, where hydrogen leaves the cells and potassium is drawn inward. Vomiting and nasogastric suction produce that picture, not ketoacidosis. Option c is incorrect because chloride tracks bicarbonate loss rather than the hydrogen exchange. It climbs in diarrheal acidosis to preserve charge balance, but it is not the shift acidemia drives across cell membranes. Option d is incorrect because sodium is governed by water balance and volume status rather than by pH. Hydrogen trades places with potassium, the other major intracellular cation, not with sodium.

Correct Answer: Proceed with the radial arterial puncture

Color returning to the palm within about five to fifteen seconds shows that ulnar and collateral flow can perfuse the hand alone. The radial artery may therefore be punctured safely. Option a is incorrect because a prompt return of color is the result the nurse wanted. Repeating the maneuver on the other wrist delays a sample that can be drawn here now. Option b is incorrect because only a palm that stays pale beyond fifteen seconds signals inadequate collateral circulation. Reporting an adequate finding as unsafe would delay treatment based on a normal result. Option d is incorrect because the femoral site is reserved for situations where the radial artery cannot be used. It is deeper, harder to compress afterwards, and carries greater bleeding risk.

Correct Answer: Notify the provider and stop potassium sources

The peaked T wave is the first sign that a rising potassium has altered cardiac conduction, and the next steps are a widening QRS and ventricular fibrillation. The provider is notified and every potassium source is stopped. Option a is incorrect because charting a lethal trajectory without acting on it wastes the warning the strip is giving. An ECG change in hyperkalemia always outranks the cramps and the loose stools. Option b is incorrect because drinking water does not lower a potassium level, since potassium sits almost entirely inside cells and is barely diluted. A client who has missed dialysis also cannot handle the extra volume. Option c is incorrect because the loose stools come from increased gut motility driven by the potassium itself, not from an infection. Chasing a culture delays the cardiac care this rhythm demands right now.

Correct Answer: Obtain a serum magnesium level

Carpopedal spasm during cuff inflation is a positive Trousseau sign, and that sign is positive in hypomagnesemia as well as hypocalcemia. With calcium and albumin normal, magnesium is the cation left to explain the irritability. Option b is incorrect because potassium disturbance produces weakness, cramps and ECG change rather than carpopedal spasm. Potassium does not stabilize the nerve membrane the way the divalent cations do, so it cannot cause this posture. Option c is incorrect because a high phosphate causes tetany only by pulling the calcium down, and this client's calcium is already normal. Checking phosphate would not explain a spasm occurring at a normal calcium. Option d is incorrect because sodium governs water distribution and osmolality, not the firing threshold of peripheral nerves. Neither a high nor a low sodium produces the hand posture seen during this blood pressure measurement.

Correct Answer: It becomes free water once dextrose is metabolized

The dextrose is oxidized within minutes, leaving water with no effective solute. Five percent dextrose in water is isotonic in the bag and hypotonic in the body, so only about a twelfth stays intravascular. Option a is incorrect because the measured osmolarity of the bag is close to plasma, which is why texts call it isotonic. That label stops holding as soon as the sugar is taken into cells. Option b is incorrect because hypertonic describes the dextrose solutions built on a saline base, such as dextrose in half normal saline. Plain dextrose in water sits below plasma osmolarity, not above it. Option c is incorrect because a liter given to a hemorrhaging client delivers only about eighty milliliters of plasma expansion. Resuscitation demands an isotonic crystalloid or blood, never a fluid that leaves the vessel.

Correct Answer: Measure and record hourly urine output amounts

Measuring and recording output is a standardised task with a predictable outcome, which assistive personnel may perform. Evaluating a breathing pattern, titrating insulin and deciding on potassium replacement all require nursing judgement. Option b is incorrect because judging whether Kussmaul respirations are deepening is an assessment of compensation. Assistive personnel may report that breathing looks laboured, but they cannot evaluate what the change means. Option c is incorrect because titrating a high alert infusion against glucose results demands licensed judgement and carries serious risk. Insulin rate changes can never be handed to unlicensed staff. Option d is incorrect because potassium falls steeply once insulin drives it back into cells, so the timing of replacement rests on serial values. That decision belongs to the nurse and prescriber.

Correct Answer: Recording the morning weight on the same scale

Obtaining and recording a daily weight is a standardized task within the scope of assistive personnel. The nurse still interprets the trend, but measuring on the same scale each morning may be delegated safely. Option a is incorrect because skin turgor is part of a nursing assessment and requires clinical judgment about hydration. Assessment cannot be handed off, even when the technique looks simple to perform at the bedside. Option b is incorrect because titrating an infusion is a nursing responsibility tied to ongoing evaluation of volume status. Unlicensed staff may not adjust therapy, and a rate change requires a provider order as well. Option d is incorrect because client education belongs to the registered nurse because it demands evaluation of understanding. Explaining why standing slowly prevents a fall involves teaching, which falls outside the assistive role entirely.

Correct Answer: Replacing chloride lets the kidney release excess bicarbonate

Vomiting loses hydrochloric acid, chloride and volume together. Without chloride the kidney cannot excrete bicarbonate efficiently, so restoring chloride and volume with sodium chloride corrects the alkalosis, and potassium is replaced alongside. Option a is incorrect because sodium chloride is a neutral solution and contains no acid. Its benefit comes from replacing the chloride and volume that were lost with the gastric contents. Option c is incorrect because slowed breathing is the body's own compensation and is already happening. Fluid therapy does not alter the respiratory rate, and deliberate hypoventilation would only worsen oxygenation. Option d is incorrect because aldosterone rises in response to volume depletion rather than being blocked by sodium. Restoring volume switches the hormone off, which then stops the ongoing potassium and hydrogen losses.