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 B
Explanation
Rationale:
A. This describes a second-degree heart block, specifically Mobitz Type I (Wenckebach).
B. A PR interval greater than 0.20 seconds is characteristic of first-degree heart block.
C. This describes third-degree heart block, also known as complete heart block.
D. An irregular R-R interval is not specific to first-degree heart block.
Correct Answer is B
Explanation
Rationale:
A. Looking for P waves is important for assessing atrial activity, but it does not directly calculate heart rate.
B. Counting how many QRS complexes occur in a 6-second strip and multiplying by 10 is a quick and accurate way to calculate heart rate.
C. Reading the monitor or ECG interpretation provides information about the rhythm and morphology of the heart, but it does not directly calculate heart rate.
D. Measuring T waves is important for assessing cardiac repolarization, but it does not directly calculate heart rate.
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