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.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. A weight gain of 0.5 kg (1 lb) in a week is not typically concerning for heart failure exacerbation.
B. Skipping a dose of a diuretic can lead to fluid retention and exacerbate heart failure symptoms.
C. Weighing daily is important for monitoring fluid retention, but the specific time of day is not as crucial as consistent timing.
D. A weight gain of 2 lbs. in 24 hours can indicate fluid retention and worsening heart failure.
Correct Answer is C
Explanation
Rationale:
A. This is wrong because the ECG leads show ST segment elevation.
B. Stable angina may present with ST segment depression in an ECG unlike in the strip shown above which depicts an ST segment elevation.
C. This is correct because of the ST segment elevation.
D. Unstable angina may have hyperacute T wave, flattening of the T waves, inverted T waves or an ST depression unlike in the above ECG strip.
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