A nurse is preparing a client with Crohn’s disease for a barium enema. What should the nurse do the day before the test?

Choice A: Tachycardia

Tachycardia, defined as a heart rate exceeding 100 beats per minute, can affect the accuracy of pulse oximetry readings. When the heart beats too quickly, it may not fill with enough blood between beats, leading to reduced perfusion and oxygen delivery to tissues. However, while tachycardia can influence the readings, it is not the most significant factor compared to hypotension.

Choice B: Hypotension

Hypotension, or low blood pressure, significantly impacts pulse oximetry accuracy. When blood pressure is low, there is reduced perfusion to peripheral tissues, including the extremities where pulse oximeters are typically placed. This reduced perfusion can lead to inaccurate readings, as the device may not detect sufficient blood flow to measure oxygen saturation accurately. Hypotension is a critical factor that can alter pulse oximetry values, making it the most relevant choice.

Choice C: Tachypnea

Tachypnea, or rapid breathing, can affect oxygen levels in the blood but does not directly interfere with the pulse oximeter’s ability to measure oxygen saturation. While it indicates respiratory distress and can lead to hypoxemia, the pulse oximeter can still provide accurate readings unless accompanied by other factors like low perfusion.

Choice D: Fever

Fever can cause peripheral vasodilation, which might theoretically affect pulse oximetry readings by altering blood flow to the extremities. However, this effect is generally minimal compared to the impact of hypotension. Fever alone is unlikely to cause significant inaccuracies in pulse oximetry measurements.

Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication

Choice A Reason:

Assessment: Patient denies vomiting

This choice is not directly related to the effectiveness of Kayexalate. Vomiting can be a symptom of hyperkalemia, but the absence of vomiting does not indicate that the medication is working. Kayexalate works by binding potassium in the intestines and removing it through the stool, so the presence of bowel movements is a more direct indicator of its effectiveness.

Choice B Reason:

ECG: Flattening of QRS complex angle

Flattening of the QRS complex angle is not a typical ECG change associated with hyperkalemia or its treatment. Hyperkalemia typically causes widening of the QRS complex, and effective treatment would normalize this. Therefore, this choice is not correct.

Choice C Reason:

ECG: Widening of the QRS complex

Widening of the QRS complex is a sign of hyperkalemia, not its resolution. If the medication is effective, the QRS complex should return to a normal width. Therefore, this choice is not correct.

Choice D Reason:

Assessment: Patient consumed 60% of meal

While nutritional intake is important, it is not a direct indicator of the effectiveness of Kayexalate. The medication’s effectiveness is better assessed by changes in potassium levels and related symptoms, not by meal consumption.

Choice E Reason:

Assessment: Patient denies nausea

Similar to vomiting, nausea can be a symptom of hyperkalemia, but the absence of nausea does not indicate that the medication is working. The effectiveness of Kayexalate is better assessed by the presence of bowel movements and changes in potassium levels.

Choice F Reason:

Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication

This is the correct answer. Kayexalate works by binding potassium in the intestines and removing it through the stool. The presence of bowel movements indicates that the medication is working to remove potassium from the body. This is a direct and relevant assessment finding.

Choice G Reason:

ECG: Shortening of P wave duration

Shortening of the P wave duration is not a typical ECG change associated with hyperkalemia or its treatment. Therefore, this choice is not correct.

Choice H Reason:

Assessment: Patient denies pain

Pain is not a typical symptom of hyperkalemia, and its absence does not indicate that the medication is working. Therefore, this choice is not correct.

Choice I Reason:

ECG: Reduction of T wave amplitude

Reduction of T wave amplitude can be a sign of hypokalemia, not hyperkalemia. Effective treatment of hyperkalemia would normalize the T wave amplitude, not reduce it. Therefore, this choice is not correct.