A client recovering from cardiac surgery experiences a dysrhythmia, noted on the telemetry monitor. Which assessment finding is most likely to have contributed to the development of the dysrhythmia?

Reference Range:

Total Calcium [8.4 to 10.6 mg/dL (2.10 to 2.50 mmol/L)]

Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]

Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Calcium level 7.2 mg/dL (1.8 mmol/L).

Potassium level 3.8 mg/dl. (3.8 mmol)

Sodium level 140 mEq/L (140mmol/L).

Oxygen saturation level 97%.

Answer and Explanation

The Correct Answer is A

A.   This calcium level is below the normal reference range (8.4 to 10.6 mg/dL or 2.10 to 2.50 mmol/L), indicating hypocalcemia. Calcium plays a crucial role in cardiac muscle contraction and electrical conduction. Low calcium levels can lead to various cardiac dysrhythmias, including prolonged QT intervals and increased risk of ventricular arrhythmias.

B.   This potassium level falls within the normal range (3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L). Potassium is essential for maintaining normal cardiac rhythm, but a level of 3.8 mg/dL is not abnormal and, therefore, is less likely to be the cause of a dysrhythmia compared to abnormal levels.
C.   This sodium level is within the normal reference range (136 to 145 mEq/L or 136 to 145 mmol/L). Sodium levels typically do not directly cause dysrhythmias unless they are extremely high or low, which is not the case here. Thus, a sodium level of 140 mEq/L is not likely to be the primary contributor to the dysrhythmia.
D.   This oxygen saturation level is considered normal (95% to 100%). While oxygenation is critical for overall heart function and can influence cardiac health, a saturation level of 97% is not likely to be a direct cause of a dysrhythmia, especially if it falls within the normal range.

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Correct Answer is C

Explanation

A. While assessing peripheral pulses is important, it's not the priority in this situation. The primary concern is the rectal bleeding.
B. These exercises are important to prevent postoperative complications like pneumonia, but they are not the immediate priority when a patient is experiencing rectal bleeding.
C. Assessing the abdomen will help determine the severity of the bleeding, identify any signs of abdominal distention or tenderness, and provide crucial information for further interventions.
D. Monitoring fluid intake and output is important for any patient, but it's not the initial priority when a patient is actively bleeding.

A. Take the diuretic every day, regardless of weight loss or muscle weakness. B. Weigh yourself daily at the same time and report excessive weight loss. C. Limit fluid intake while taking the diuretic to reduce fluid retention. D. Stop taking the medication when the edema in the lower extremities subsides.

Correct Answer is B

Explanation

A. Diuretics can cause electrolyte imbalances and dehydration, leading to muscle weakness. The patient should report any signs of muscle weakness to the healthcare provider.
B. Weight is a good indicator of fluid loss. Monitoring daily weight and reporting excessive weight loss helps to evaluate the effectiveness of the diuretic and detect potential complications.
C. Limiting fluid intake while on a diuretic can lead to dehydration and electrolyte imbalances. Adequate fluid intake is essential.
D. Diuretics are often prescribed for long-term management of edema. The patient should not stop taking the medication without consulting the healthcare provider.

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Naxlex Comprehensive Predictor Exams

An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

Correct Answer is C

Explanation

The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

Correct Answer is B

Explanation

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