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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

PacO2 50 mm Hg. Choice A rationale:

Potassium levels are not directly related to respiratory acidosis. Potassium levels may be affected in certain conditions, but they are not specific indicators of respiratory acidosis.

Choice B rationale:

HCO3- (bicarbonate) levels may be elevated in metabolic alkalosis, not respiratory acidosis. In respiratory acidosis, the primary abnormality is an increased PacO2, not HCO3-.

Choice C rationale:

The partial pressure of carbon dioxide (PacO2) is a key parameter in diagnosing respiratory acidosis. In this case, a PacO2 of 50 mm Hg suggests hypoventilation and an excess of carbon dioxide in the blood, contributing to acidosis.

Choice D rationale:

The pH level given (pH 7.45) is within the normal range, which contradicts the diagnosis of respiratory acidosis. In respiratory acidosis, the pH would be expected to be below the normal range of 7.35-7.45 due to increased carbon dioxide levels.

A. Prepare to administer a sedative. B. Prepare for mechanical ventilation. C. Massage the calf area for tenderness. D. Assess for indications of pulmonary embolism.

Correct Answer is D

Explanation

The correct answer isd. Assess for indications of pulmonary embolism.

Choice A rationale:

Administering a sedative is not appropriate as the priority intervention. Sedatives can depress respiratory function, which is already compromised in this patient.

Choice B rationale:

Preparing for mechanical ventilation might be necessary if the patient’s condition worsens, but it is not the immediate priority. The priority is to identify the underlying cause of the symptoms.

Choice C rationale:

Massaging the calf area for tenderness is not relevant in this context. While calf tenderness can be a sign of deep vein thrombosis (DVT), which can lead to pulmonary embolism, the immediate priority is to assess for pulmonary embolism directly.

Choice D rationale:

Assessing for indications of pulmonary embolism is the priority because the patient’s symptoms (shortness of breath, chest pain, recent use of birth control pills, smoking history, and abnormal ABG values) strongly suggest a pulmonary embolism.Early identification and treatment are crucial to prevent further complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output volumes should the nurse notify the patient's healthcare provider?

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?

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