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 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.

A. Patient with bulimia. B. Patient with COPD. C. Patient with venous stasis ulcer. D. Patient on dialysis.

Correct Answer is A

Explanation

Choice A rationale: Patients with bulimia are at increased risk for developing metabolic alkalosis due to recurrent vomiting, which leads to loss of hydrochloric acid from the stomach and results in an elevated blood bicarbonate level.

Choice B rationale: Patients with COPD are more likely to develop respiratory acidosis due to retention of carbon dioxide, not metabolic alkalosis.

Choice C rationale: Patients with venous stasis ulcers do not have a direct association with metabolic alkalosis.

Choice D rationale: Patients on dialysis are more likely to experience metabolic acidosis due to impaired kidney function and inability to excrete acid effectively.

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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

Correct Answer is D

Explanation

The nurse is reviewing the health problems for a group of assigned patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis?

Correct Answer is A

Explanation

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