A client is in the oliguric phase of acute kidney injury (AKI) which was caused by massive tissue trauma. The nurse notes peaked T-waves and a widened QRS complex on the cardiac monitor. What is the first action the nurse should take?

Check the client's most recent potassium level

Administer a bolus of 1,000 mL of normal saline

Administer potassium chloride intravenously (IV)

Administer sodium polystyrene sulfonate (Kayexalate)

Answer and Explanation

The Correct Answer is A

A.   Peaked T-waves and a widened QRS complex on an ECG are often signs of hyperkalemia, which is an elevated potassium level in the blood. This can be a serious complication of acute kidney injury (AKI), especially in the oliguric phase when the kidneys are unable to effectively excrete potassium.A
B.   While fluid management is important in AKI, administering a bolus of normal saline is not the first priority in the presence of suspected hyperkalemia. The primary concern is to address the electrolyte imbalance.

C.   Administering potassium chloride would worsen hyperkalemia and should be avoided.
D.   Kayexalate is a medication used to treat hyperkalemia by exchanging sodium ions for potassium ions in the gastrointestinal tract. However, checking the potassium level is the first step in confirming the diagnosis and determining the appropriate treatment.

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Correct Answer is A

Explanation

A. Loss of peripheral vision is a hallmark sign of primary open-angle glaucoma. In POAG, increased intraocular pressure causes damage to the optic nerve, leading to a gradual loss of peripheral vision. This vision loss is often subtle and progresses slowly, making it difficult for individuals to notice until the condition is advanced.

B. Opacity of the lens is characteristic of cataracts, not glaucoma. Cataracts involve the clouding of the eye's natural lens, which leads to blurred vision and difficulties with seeing clearly, particularly in bright light. While cataracts and glaucoma can occur simultaneously, opacity of the lens is not indicative of POAG.
C. Decrease in color perception can be associated with various eye conditions, including age-related macular degeneration (AMD) and certain types of retinal diseases. While it can occur in glaucoma as the disease progresses, it is not the primary or most characteristic sign of POAG.
D. Pain and purulent discharge are more associated with acute conditions such as conjunctivitis (pink eye) or an eye infection, rather than primary open-angle glaucoma. POAG typically presents without pain or discharge, as it is a chronic condition with a gradual onset of symptoms.

A. Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. B. After administration, the client will experience worsening facial weakness and ptosis. C. After administration of the medication, there will be no change in the status of the ptosis or facial weakness. D. The client will have elimination of symptoms lasting at least 24 hours after the administration of the medication.

Correct Answer is A

Explanation

This is the correct expected outcome if the test is positive for myasthenia gravis. Edrophonium works quickly to increase acetylcholine levels, leading to temporary improvement in muscle strength. In a patient with myasthenia gravis, administration of edrophonium typically results in a rapid improvement in symptoms like facial weakness and ptosis within 30 to 60 seconds, with the effects lasting for a few minutes. This brief improvement is indicative of a positive result for myasthenia gravis.
B.A Worsening symptoms after administration of edrophonium are not expected and could indicate an adverse reaction or incorrect diagnosis. In myasthenia gravis, edrophonium typically improves symptoms rather than worsening them.
C. No change in symptoms would be unexpected in the case of myasthenia gravis. If edrophonium is effective, there should be a noticeable improvement in symptoms. If there is no change, it might suggest a diagnosis other than myasthenia gravis or that the test is inconclusive.
D. This outcome is not expected. Edrophonium has a very short duration of action, typically relieving symptoms for only a few minutes. The effects do not last for 24 hours. A longer-lasting improvement might be observed with other treatments for myasthenia gravis, such as anticholinesterase medications like pyridostigmine, but not with edrophonium.

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A client is in the oliguric phase of acute kidney injury (AKI) which was caused by massive tissue trauma. The nurse notes peaked T-waves and a widened QRS complex on the cardiac monitor. What is the first action the nurse should take?

Nursing Test Bank

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A nurse in an ophthalmology clinic is assessing a client who has suspected primary open-angle glaucoma (PAOG). Which assessment finding would support a diagnosis of this type of glaucoma?

Correct Answer is A

Explanation

The nurse is assisting while a neurologist administers an edrophonium (Tensilon) test to a client with facial weakness and ptosis. If the test is positive for myasthenia gravis, which outcome would the nurse observe?

Correct Answer is A

Explanation

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