During a home visit, a client informs the nurse about feeling like the heart is skipping beats. When reviewing the client's record, the nurse notes that the client is taking hydrochlorothiazide. Based on these assessment data, the nurse plans to obtain a blood sample to check for which condition?
Hypokalemia.
Hyponatremia
Hyperphosphatemia.
Hypermagnesemia.
The Correct Answer is A
A. Hypokalemia: Hydrochlorothiazide is a thiazide diuretic that can cause potassium loss through increased urine production. A common side effect of thiazide diuretics is hypokalemia, which can lead to symptoms such as palpitations or the sensation of the heart skipping beats. Therefore, it is crucial to check the client’s potassium levels to determine if hypokalemia is contributing to the client's symptoms.
B. Hyponatremia: While thiazide diuretics can affect sodium levels, hypokalemia is more directly associated with the symptoms described. Hyponatremia (low sodium levels) might also occur but is less commonly linked to the symptom of a skipped heartbeat compared to hypokalemia.
C. Hyperphosphatemia: Hydrochlorothiazide is not known to cause significant changes in phosphate levels, and hyperphosphatemia is not typically associated with the sensation of skipped heartbeats.
D. Hypermagnesemia: This condition, which involves elevated magnesium levels, is not a common side effect of hydrochlorothiazide. Hypokalemia is a more relevant concern for the symptoms described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Hypertension: Phenytoin is primarily used to manage seizures, and hypertension is not a common side effect associated with its use. While monitoring blood pressure is important for overall health, it is not specifically indicated for detecting common side effects of phenytoin.
B) Peripheral edema: Peripheral edema is not a typical side effect of phenytoin. Common side effects are usually related to oral health and skin changes rather than fluid retention or swelling in the extremities.
C) Hematuria: Hematuria, or blood in the urine, is not commonly associated with phenytoin use. This side effect is more relevant to other medications or conditions, and while monitoring for overall health changes is important, it is not a primary concern with phenytoin.
D) Gingival hyperplasia: Phenytoin is well-known for causing gingival hyperplasia, which is the overgrowth of gum tissue. This is a common and notable side effect of long-term phenytoin use, making it important for the nurse to assess for this symptom in clients receiving the medication.
Correct Answer is B
Explanation
A. Expresses that they cannot get enough air to breathe: While this is concerning, it is less specific than a respiratory rate finding for opioid overdose.
B. Respiratory rate of 7 breaths/minute: This indicates severe respiratory depression, a critical sign of opioid overdose, which necessitates immediate administration of naloxone.
C. Intercostal retractions and bilateral wheezing on auscultation: These signs suggest respiratory distress but do not directly indicate an opioid overdose.
D. Pulse oximeter reading of 89% on room air: While low, this reading does not specifically indicate opioid overdose unless accompanied by respiratory depression.
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