A nurse is caring for a client who is receiving potassium chloride 40 mEq IV every 4 hr. Which of the following findings indicate the client is becoming hyperkalemic?

Hypoactive bowel sounds

Sinus rhythm with peaked T waves

Irritability and anxiety

Shallow respirations

Answer and Explanation

The Correct Answer is B

A. Hypoactive bowel sounds: Hyperkalemia typically causes increased gastrointestinal motility, leading to hyperactive bowel sounds and diarrhea rather than hypoactive bowel sounds.

B. Sinus rhythm with peaked T waves: Elevated potassium levels affect cardiac conduction, leading to ECG changes such as peaked T waves, prolonged PR intervals, and widened QRS complexes. These findings indicate early hyperkalemia and require immediate attention.

C. Irritability and anxiety: While hyperkalemia can cause neuromuscular symptoms, such as muscle weakness and paresthesia, irritability and anxiety are more commonly associated with hypoglycemia or hypoxia rather than hyperkalemia.

D. Shallow respirations: Severe hyperkalemia can lead to muscle weakness, including respiratory muscles, but this occurs in later stages. Shallow respirations are more commonly associated with conditions like respiratory depression or metabolic alkalosis.

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Correct Answer is B

Explanation

A. 1:1 ratio of P to QRS waves: Atrial fibrillation is characterized by chaotic atrial electrical activity, leading to the absence of distinct P waves. A 1:1 ratio of P to QRS waves is seen in normal sinus rhythm, not atrial fibrillation.

B. Absence of P waves: Atrial fibrillation causes rapid, disorganized atrial depolarization, resulting in the loss of identifiable P waves on ECG. Instead, fibrillatory waves are seen, and the ventricular response is irregularly irregular.

C. Prolonged PR interval: The PR interval represents the time between atrial and ventricular depolarization. In atrial fibrillation, there is no coordinated atrial depolarization, making the PR interval unmeasurable rather than prolonged.

D. Prolonged QT interval: A prolonged QT interval is associated with conditions like electrolyte imbalances, certain medications, and congenital syndromes, but it is not a typical feature of atrial fibrillation.

A. Pain level B. Urinary output C. Echocardiogram results D. Heart rate E. Blood pressure F. Respiratory rate G. Oxygenation saturation

Correct Answer is ["A","D","E","G"]

Explanation

Pain level: The client's reported pain level decreased from 7 to 5 after receiving nitroglycerin and oxygen therapy. A reduction in pain indicates that the treatment is effective and the client's condition is improving.
Heart rate: The heart rate decreased from 120/min to 100/min between assessments, suggesting improved cardiac function and stability. A lower heart rate can indicate a better response to treatment and improved hemodynamic status.
Blood pressure: The blood pressure improved from 176/82 mm Hg to 110/62 mm Hg, indicating a more stable hemodynamic status. However, it is important to ensure that the blood pressure does not drop too low; overall, the trend suggests an improvement in circulation.
Oxygenation saturation: The oxygen saturation improved from 89% on room air to 93% after oxygen therapy was initiated. An increase in oxygen saturation indicates improved respiratory function and effective oxygenation, which is critical for recovery in clients with cardiac issues.

Urinary output: There is no documented information regarding the client's urinary output in the provided data, making it difficult to assess improvement in this area. Monitoring urinary output is essential for evaluating kidney function and fluid balance, but it cannot be determined from the available information.
Echocardiogram results: The echocardiogram results indicated a myocardial infarction, which does not show improvement but rather confirms the severity of the client's condition. While treatment may address the effects of the infarction, the diagnosis itself indicates ongoing concern.
Respiratory rate: The respiratory rate remained at 22/min, which is still elevated. While it is unchanged, an improvement would typically be reflected by a decrease in the respiratory rate, indicating better respiratory status. The persistent elevated rate suggests that further monitoring and interventions may still be needed.

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A nurse is caring for a client who is receiving potassium chloride 40 mEq IV every 4 hr. Which of the following findings indicate the client is becoming hyperkalemic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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