A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which electrolyte imbalance?
Hypocalcemia.
Hypercalcemia.
Hyperkalemia.
Hypokalemia.
The Correct Answer is C
Choice A rationale:
Hypocalcemia refers to low levels of calcium in the blood, which can present with symptoms like muscle cramps, numbness, and tingling. However, this choice is not relevant to the patient's symptoms in the scenario.
Choice B rationale:
Hypercalcemia is an electrolyte imbalance characterized by high levels of calcium in the blood. It can lead to ECG changes and symptoms like muscle weakness, confusion, and constipation. However, this is not the correct answer in the given scenario.
Choice C rationale:
The patient's symptoms of ECG changes and muscle weakness are consistent with hyperkalemia. Spironolactone is a potassium-sparing diuretic, and its use can lead to increased potassium levels in the blood (hyperkalemia), which can affect the heart's electrical activity and cause muscle weakness.
Choice D rationale:
Hypokalemia is a condition where there is a low level of potassium in the blood. It can lead to muscle weakness, ECG changes, and other symptoms, but it is not the correct answer in this specific situation involving spironolactone use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
The correct answer is choiceC. Monitor the injection site for redness,D. Use an infusion controller for the IV, andE. Monitor fluid intake and output.
Choice A rationale:
Adding the ordered dose to the IV hanging is incorrect because potassium chloride should never be added to an already hanging IV solution due to the risk of uneven distribution and potential overdose.
Choice B rationale:
Administering the dose IV push over 3 minutes is incorrect because potassium chloride should never be given by direct IV injection.It must always be diluted and administered slowly to prevent cardiac complications.
Choice C rationale:
Monitoring the injection site for redness is correct because potassium chloride can cause irritation and phlebitis at the injection site.
Choice D rationale:
Using an infusion controller for the IV is correct because it ensures the potassium chloride is administered at a controlled rate, reducing the risk of rapid infusion and potential cardiac issues.
Choice E rationale:
Monitoring fluid intake and output is correct because it helps assess the patient’s overall fluid balance and detect any signs of fluid overload or deficit, which is crucial when administering potassium.
Correct Answer is A
Explanation
Hypocalcemia. Action to Take 1: Prepare to check a serum albumin level.
Rationale:
Hypocalcemia can be influenced by changes in serum albumin levels, as calcium may bind to albumin. Correcting calcium levels based on albumin can help determine the actual calcium status. Action to Take 2: Request a STAT ECG. Rationale: Hypocalcemia can lead to prolonged QT intervals on an electrocardiogram (ECG). A STAT ECG is necessary to assess cardiac function and detect any potential arrhythmias. Parameters to Monitor 1: Serum bicarbonate level. Rationale: Monitoring serum bicarbonate levels can help assess the client's acid-base balance and metabolic status. Abnormal bicarbonate levels may indicate metabolic disturbances. Parameters to Monitor 2: Intake and Output. Rationale: Monitoring intake and output is essential to evaluate the client's fluid balance and kidney function. Hypocalcemia can impact renal function, and assessing urine output is crucial.
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