A nurse is reviewing the EKG strip of a client who has End Stage Renal Disease (ESRD) and has missed hemodialysis. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hyperkalemia?

Prolonged P-R interval

Peaked T waves

Elevated ST segment

Inverted P wave

Answer and Explanation

The Correct Answer is B

A. Prolonged P-R interval: A prolonged P-R interval may indicate an atrioventricular (AV) block or conduction delay, but it is not specifically associated with hyperkalemia.

B. Peaked T waves: Peaked T waves are a classic EKG finding in hyperkalemia. Hyperkalemia can affect cardiac repolarization, leading to tall, peaked T waves on the EKG.

C. Elevated ST segment: An elevated ST segment may indicate myocardial injury or ischemia but is not typically associated with hyperkalemia.

D. Inverted P wave: An inverted P wave may indicate atrial enlargement or conduction abnormalities but is not specifically associated with hyperkalemia.

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Correct Answer is B

Explanation

A. The duration of contact with the agent: While duration is important, it alone does not provide a comprehensive understanding of radiation burns, which require considering the type and dose of radiation as well.

B. The type, dose, and length of exposure: These factors are crucial in assessing the severity and necessary treatment for radiation burns. The type of radiation (e.g., alpha, beta, gamma), the dose

received, and the length of exposure all determine the extent of tissue damage and appropriate interventions.

C. The pathway of flow through the body: This is more relevant to internal contamination with radioactive substances rather than external radiation burns.

D. The temperature to which the skin is heated: Temperature is a factor in thermal burns, not radiation burns. Radiation burns result from energy transfer, not heat.

A. Document how many inches the tube has been inserted. B. Auscultate both lungs for the presence of breath sounds. C. Secure the endotracheal tube to prevent dislodgement. D. Obtain a chest x-ray to ensure correct tube placement.

Correct Answer is B

Explanation

A. Document how many inches the tube has been inserted: While documentation of the tube insertion depth is important, it is not the highest priority immediately after intubation. Ensuring proper placement and ventilation take precedence.

B. Auscultate both lungs for the presence of breath sounds: This is the priority action to confirm that the endotracheal tube is correctly placed in the trachea and that both lungs are being ventilated adequately. Absence of breath sounds on one side could indicate mainstem intubation or displacement of the tube.

C. Secure the endotracheal tube to prevent dislodgement: Securing the tube is important, but it should be done after confirming proper placement and ventilation.

D. Obtain a chest x-ray to ensure correct tube placement: While a chest x-ray is often performed after intubation to confirm tube placement, it is not the immediate priority. Auscultation provides more immediate feedback on the effectiveness of ventilation.

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A nurse is reviewing the EKG strip of a client who has End Stage Renal Disease (ESRD) and has missed hemodialysis. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hyperkalemia?

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Naxlex Comprehensive Predictor Exams

A client presents to the emergency department seeking treatment for radiation burns. The nurse should develop the client's plan of care based on which of the following?

Correct Answer is B

Explanation

A nurse is caring for a client who experienced sudden onset of dyspnea, tachycardia, oxygen saturation of 82%, and has been intubated with an endotracheal tube. The nurse should perform which priority action immediately after the tube is placed in the trachea?

Correct Answer is B

Explanation

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