A client recovering from cardiac surgery experiences a dysrhythmia, noted on the telemetry monitor. Which assessment finding is most likely to have contributed to the development of the dysrhythmia?

Reference Range:

Total Calcium [8.4 to 10.6 mg/dL (2.10 to 2.50 mmol/L)]

Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]

Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Calcium level 7.2 mg/dL (1.8 mmol/L).

Potassium level 3.8 mg/dl. (3.8 mmol)

Sodium level 140 mEq/L (140mmol/L).

Oxygen saturation level 97%.

Answer and Explanation

The Correct Answer is A

A.   This calcium level is below the normal reference range (8.4 to 10.6 mg/dL or 2.10 to 2.50 mmol/L), indicating hypocalcemia. Calcium plays a crucial role in cardiac muscle contraction and electrical conduction. Low calcium levels can lead to various cardiac dysrhythmias, including prolonged QT intervals and increased risk of ventricular arrhythmias.

B.   This potassium level falls within the normal range (3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L). Potassium is essential for maintaining normal cardiac rhythm, but a level of 3.8 mg/dL is not abnormal and, therefore, is less likely to be the cause of a dysrhythmia compared to abnormal levels.
C.   This sodium level is within the normal reference range (136 to 145 mEq/L or 136 to 145 mmol/L). Sodium levels typically do not directly cause dysrhythmias unless they are extremely high or low, which is not the case here. Thus, a sodium level of 140 mEq/L is not likely to be the primary contributor to the dysrhythmia.
D.   This oxygen saturation level is considered normal (95% to 100%). While oxygenation is critical for overall heart function and can influence cardiac health, a saturation level of 97% is not likely to be a direct cause of a dysrhythmia, especially if it falls within the normal range.

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Correct Answer is A

Explanation

A. The client's symptoms of headache, blurred vision, vertigo, and nausea, even without abnormal vital signs, are suggestive of potential neurological complications from a head injury, such as increased intracranial pressure (ICP). This requires immediate attention and evaluation.
B. While the client is experiencing discomfort, it is secondary to the potential neurological issue.
C. The client's nutritional status is a concern, but it is not the priority at this time, given the potential neurological implications of the client's symptoms.
D. While the client's anxiety is understandable, it is not the primary concern given the more immediate health risk.

A. Implement seizure precautions. B. Begin straining all urine. C. Administer a PRN dose of a laxative. D. Initiate cardiac telemetry.

Correct Answer is B

Explanation

A. While hypercalcemia associated with hyperparathyroidism can lead to neurological symptoms, seizures are not a typical presentation of kidney stones.
B. Sudden onset of severe flank pain in a client with hyperparathyroidism is highly suggestive of a kidney stone. Straining the urine to check for stones is a crucial nursing action.
C. Laxatives are not indicated for the management of kidney stones.
D. While hypercalcemia can lead to cardiac arrhythmias, this is not the immediate priority when the client is experiencing severe flank pain suggestive of kidney stones.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

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