Which serum electrolyte value alerts the nurse to the possibility of hyperaldosteronism?
Serum sodium, 150 mmol/L; serum potassium, 2.5 mmol/L
Serum sodium, 140 mmol/L; serum potassium, 5.0 mmol/L
Serum sodium, 130 mmol/L; serum potassium, 7.5 mmol/L
Serum sodium, 130 mmol/L; serum potassium, 2.5 mmol/L
The Correct Answer is A
A. Hyperaldosteronism causes sodium retention and potassium excretion, leading to elevated serum sodium levels and low potassium levels. A serum potassium level of 2.5 mmol/L is indicative of hypokalemia, which is a classic finding in hyperaldosteronism.
B. This serum electrolyte pattern (normal sodium and potassium) is not suggestive of hyperaldosteronism.
C. In hyperaldosteronism, the serum sodium is typically elevated, but the potassium level is very low, not elevated as seen in this option.
D. While low potassium is indicative of hyperaldosteronism, the sodium level is abnormally low in this case, which is not typical for this condition. Hyperaldosteronism typically presents with elevated sodium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. After administering a carbohydrate source (e.g., 6 oz of orange juice), the nurse should reassess the patient's blood glucose level. If the glucose is still below the target range (typically above 70 mg/dL), the next step is to give an additional 15 grams of carbohydrate to raise the blood sugar. This is a standard approach for mild to moderate hypoglycemia.
B. Giving 25 to 50 ml of 50% glucose IV is typically reserved for patients who are severely hypoglycemic and unable to swallow or are unresponsive. This method is appropriate when the patient cannot take oral glucose, but the client in this scenario is still conscious.
C. Administering 1 mg IM glucagon is used when a patient is unable to ingest glucose orally and is unresponsive or vomiting. It stimulates the liver to release stored glucose, but this is not necessary in a conscious patient who can swallow.
D. Administering a 5% to 10% dextrose infusion is typically used in more severe cases of hypoglycemia, especially when IV access is established, and the patient is unable to take oral glucose. This would not be necessary for a patient who can safely swallow.
Correct Answer is B
Explanation
A. Constant bubbling in the suction-control chamber is normal as it indicates that the suction is active and functioning as intended. The chamber should have steady bubbling when suction is applied.
B. Continuous bubbling in the water-seal chamber is abnormal and indicates a potential air leak. The water-seal chamber should only bubble intermittently with respiratory effort or changes in pressure; constant bubbling suggests that air is being introduced into the system, which could indicate a malfunction or an air leak at the insertion site or along the tubing.
C. Fluid-level fluctuations in the water-seal chamber are normal and should be observed, especially with breathing. The fluid levels will rise with inspiration and fall with expiration, reflecting the changes in pressure within the pleural space.
D. Bloody drainage in the collection chamber is expected immediately after surgery, particularly in the early postoperative period. It may be a sign of surgical site drainage, but if it becomes excessive or persists, further assessment is required. However, a small amount of blood in the collection chamber initially is not abnormal.
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