A nurse is caring for a client with a current blood potassium level of 5.4 mEq/L (3.5-5 mEq/L). Which finding would this client have?
Constipation
Polyuria
EKG with a U wave
Paresthesias of the extremities
The Correct Answer is D
A) Constipation: Elevated potassium levels (hyperkalemia) typically affect neuromuscular and cardiac function rather than gastrointestinal motility. Constipation is more commonly associated with conditions like hypokalemia or electrolyte imbalances affecting the gastrointestinal system.
B) Polyuria: Polyuria, or excessive urination, is not directly caused by hyperkalemia. It can occur due to conditions like diabetes mellitus or diabetes insipidus, or as a side effect of certain medications like diuretics. Hyperkalemia does not typically lead to increased urine output and may even lead to oliguria if severe renal impairment occurs.
C) EKG with a U wave: The presence of a U wave on an electrocardiogram (EKG) is typically associated with hypokalemia, not hyperkalemia. U waves are seen when potassium levels are low, reflecting delayed repolarization of the ventricles. In hyperkalemia, EKG changes more commonly include peaked T waves, prolonged PR interval, and widened QRS complexes.
D) Paresthesias of the extremities: Hyperkalemia can cause paresthesias, which are sensations of tingling or numbness, particularly in the extremities. This occurs due to the effect of elevated potassium levels on nerve and muscle function. As potassium is essential for maintaining normal neuromuscular function, deviations from normal levels can disrupt action potentials and lead to sensory disturbances like paresthesias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 8 hr - Infusing one unit of packed red blood cells (PRBCs) over 8 hours is too long. Typically, PRBCs are infused over a shorter period to avoid complications.
B. 4 hr - Infusing PRBCs over 4 hours is still within acceptable limits, but the standard time for PRBC transfusion is usually shorter.
C. 6 hr - Infusing PRBCs over 6 hours is longer than usual. The recommended duration for infusing one unit of PRBCs is generally shorter.
D. 2 hr - The standard time to infuse one unit of PRBCs is typically between 1.5 to 2 hours. This duration helps ensure the effective delivery of red blood cells while minimizing the risk of transfusion reactions.
Correct Answer is C
Explanation
A) The client is reporting constipation:
Constipation is a common issue with enteral feeding, often due to decreased fluid intake or lack of fiber. While it is important to manage constipation to improve comfort and bowel function, it is not as urgent as dealing with vomiting.
B) The client reports being thirsty:
Thirst can be a sign of dehydration or inadequate fluid intake. Although it should be addressed to ensure proper hydration, it is less critical compared to vomiting, which poses immediate risks.
C) The client is vomiting the enteral formula:
Vomiting is a priority concern because it can lead to aspiration, dehydration, electrolyte imbalances, and further complications. Addressing the cause of vomiting and managing it promptly is crucial for the client’s safety.
D) The client is experiencing abdominal cramping:
Abdominal cramping can be related to the feeding rate, type of formula, or intolerance. While it requires attention, it is less urgent than addressing vomiting, which could have more immediate and serious consequences.
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