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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. Lime: Lime can cause chemical burns, especially when in contact with moisture (e.g., skin or eyes), but it is less common than some other agents listed.
B. Hydrofluric acid: Hydrofluoric acid is highly corrosive and can cause severe burns upon contact with the skin or mucous membranes.
C. Bleach: Bleach, particularly sodium hypochlorite, is a common household chemical that can cause chemical burns, especially in concentrated forms.
D. Fabric softener: While fabric softeners contain chemicals, they are not typically known to cause significant chemical burns unless ingested or used improperly.
E. Gasoline: Gasoline is a flammable liquid that can cause chemical burns upon skin contact.
Correct Answer is D
Explanation
A. Inform the health care provider that there is a probable leak in the drainage system: Bubbling in the water seal chamber of a chest drainage system during client breathing is an expected finding and indicates air movement in and out of the pleural space. It does not necessarily indicate a leak in the drainage system. Documenting the observation and assessing the client for other signs of complications would be appropriate before informing the healthcare provider.
B. Encourage the client to breathe deeply so the water seal will stabilize: Deep breathing by the client will not stabilize the water seal. The bubbling occurs due to air movement in and out of the pleural space during respiration and is a normal finding.
C. Inform the health care provider that the client is ready to have the chest tube removed: Bubbling in the water seal chamber does not necessarily indicate that the client is ready to have the chest tube removed. The decision to remove a chest tube is based on various factors, including the client's clinical status and resolution of the underlying condition requiring chest drainage.
D. Document that the chest drainage system is functioning as intended: Bubbling in the water seal chamber during client breathing indicates that the chest drainage system is functioning as intended. It is an expected finding and does not typically require intervention.
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