A nurse is caring for a client who is experiencing acute kidney failure after a surgical procedure. Telemetry monitoring shows a widened QRS, frequent premature ventricular contractions, and a heart rate of 55/min. Which of the following electrolyte imbalances should the nurse identify?

Hyperkalemia.

Hypocalcemia.

Hyperglycemia.

Hypophosphatemia.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
The combination of widened QRS, frequent premature ventricular contractions (PVCs), and bradycardia (heart rate of 55/min) on telemetry monitoring suggests hyperkalemia. Elevated potassium levels in the blood can cause delayed repolarization of cardiac cells, leading to widened QRS complexes and PVCs. Bradycardia is another common manifestation of hyperkalemia.
Choice B rationale:
Hypocalcemia, characterized by low calcium levels in the blood, can lead to cardiac arrhythmias, but it typically presents with a prolonged QT interval rather than widened QRS complexes and PVCs.
Choice C rationale:
Hyperglycemia, which is high blood glucose levels, does not directly affect the electrocardiogram (ECG) parameters like QRS width or heart rate. It may have systemic effects, but it is not responsible for the ECG changes described in the scenario.
Choice D rationale:
Hypophosphatemia, or low levels of phosphate in the blood, can cause muscle weakness and may have systemic effects, but it is not associated with the specific ECG changes seen in hyperkalemia, such as widened QRS complexes and PVCs.

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Correct Answer is A

Explanation

Choice A rationale:

The client's ABG values show a pH of 7.48, PCO2 of 30 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 85 mm Hg. The elevated pH and decreased PCO2 (respiratory component) suggest respiratory alkalosis. Respiratory alkalosis occurs when there is excessive ventilation, leading to a decrease in carbon dioxide levels (hypocapnia) and subsequent alkalosis.

Choice B rationale:

Respiratory acidosis is characterized by an elevated PCO2 and decreased pH. In this case, the client's PCO2 is decreased, indicating respiratory alkalosis rather than respiratory acidosis.

Choice C rationale:

Metabolic alkalosis is characterized by an elevated HCO3 (bicarbonate) level and an increased pH. The client's HCO3 level is within the normal range, making metabolic alkalosis an incorrect identification.

Choice D rationale:

Metabolic acidosis is characterized by a decreased HCO3 level and a decreased pH. The client's HCO3 level is within the normal range, ruling out metabolic acidosis as the acid-base imbalance in this case.

A. Notify the surgeon of the temperature elevation. B. Encourage the client to drink more fluids. C. Assess the surgical incision for signs of infection. D. Monitor vital signs every 4 hr.

Correct Answer is C

Explanation

Choice A rationale:
Notifying the surgeon of the temperature elevation is important, but it is not the nurse's priority. A temperature elevation after abdominal surgery could be a sign of infection, but the immediate action should be to assess the surgical incision for any signs of infection.
Choice B rationale:
Encouraging the client to drink more fluids is a good practice to maintain hydration and promote recovery after surgery. However, it is not the nurse's priority in this situation. The elevated temperature and potential infection take precedence over increasing fluid intake.
Choice C rationale:
This is the correct answer because the nurse's priority is to assess the surgical incision for signs of infection. An elevated temperature is a significant finding after surgery, and it may indicate a surgical site infection, which requires prompt assessment and intervention.
Choice D rationale:
Monitoring vital signs every 4 hours is an essential nursing intervention after surgery, but it is not the priority when the client has an elevated temperature and a recent surgical incision.
The nurse must first assess for signs of infection before proceeding with routine vital sign monitoring.

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A nurse is caring for a client who is experiencing acute kidney failure after a surgical procedure. Telemetry monitoring shows a widened QRS, frequent premature ventricular contractions, and a heart rate of 55/min. Which of the following electrolyte imbalances should the nurse identify?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are pH 7.48, PCO2 30 mm Hg, HCO3 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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