A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
Suggest that the client use a salt substitute.
Advise the client to add citrus juices and bananas to her diet.
Obtain a 12-lead ECG
Obtain a blood sample for a serum sodium level
The Correct Answer is C
Rationale:
A. Salt substitutes often contain potassium and should be avoided in clients with hyperkalemia.
B. Citrus juices and bananas are high in potassium and should be avoided in clients with hyperkalemia.
C. A 12-lead ECG may include changes such as peaked T wave, flattened P wave, prolonged PR interval, ST depression, and prolonged QRS duration.
D. A serum sodium level should be obtained but it is not the priority in this case.
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Related Questions
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. Fluid overload can lead to increased blood pressure due to the excess fluid circulating in the body.
B. Increased heart rate is a compensatory mechanism in response to fluid volume overload.
C. Increased hematocrit is not typically associated with fluid volume overload.
D. Increased respiratory rate is a compensatory mechanism in response to fluid volume overload.
E. Increased temperature is not typically associated with fluid volume overload.
Correct Answer is B
Explanation
A. A sinus tachycardia is characterized by a sinus P wave at a rate of more than 100 per minute followed by a narrow QRS complex unlike in the strip depicted above.
B. The above ECG strip shows a ventricular tachycardia based on the wide QRS with a rate more than 120 bpm, AV dissociation and the fusion beats.
C. A complete heart block is characterized by QRS complexes being conducted at their own rates and totally independent of the P wave.
D. An idioventricular rhythm is characterized by a slow regular ventricular rhythm with a rate less than 50 bpm unlike in the above strip. It also has a prolonged QRS interval with no P wave.
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