Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank


Rationale: One medium apple with skin provides approximately 159 mg of potassium per serving, so it has the lowest potassium content of these choices. Raw spinach (oz) provides 470 mg of potassium. One large carrot has 341 mg of potassium. One medium avocado provides the highest potassium content, 1097 mg.


Test-Taking Strategy: Focus on the subject, the low potassium food. Use knowledge about the nutritional content of foods to assist in directing you to “apple.” Review the foods that are high and low in potassium content if you had difficulty with this question.


PTS: 1 DIF: Level of Cognitive Ability: Applying REF: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient- centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Nursing Sciences MSC: Integrated Process: Teaching and Learning


17. 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


ANS: 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.


Test-Taking Strategy: Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate “a client with ulcerative colitis” and “a client who has a history of long-term laxative abuse” first because they reflect gastrointestinal losses. Remember that cell destruction causes potassium shifts, which will direct you to the correct option. Also remember that Cushing’s syndrome presents a risk for hypokalemia and Addison’s disease presents a risk for hyperkalemia. If you had difficulty with this question, review the risk factors associated with hyperkalemia.


PTS: 1 DIF: Level of Cognitive Ability: Analyzing REF: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient- centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Nursing Sciences MSC: Integrated Process: Nursing Process—Assessment


Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank


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