A nurse is assessing a client who has hypokalemia and a new prescription for potassium chloride. Which of the following findings should the nurse report to the provider?
Capillary refill less than 2 seconds
Peaked T-waves on client's cardiac rhythm strip
Client report of constipation
Blood pressure 96/80 mm Hg
The Correct Answer is B
Potassium chloride is an electrolyte replenisher used to resolve hypokalemia, a state where serum potassium levels fall below 3.5 mEq/L. Potassium is essential for maintaining the resting membrane potential of excitable tissues. Correcting deficits requires precise dosing, as overcorrection leads to hyperkalemia, causing lethal cardiac conduction abnormalities and potential asystole.
Rationale:
A. A capillary refill time of less than 2 seconds is a normal clinical finding indicating adequate peripheral perfusion and cardiac output. This result suggests that the client’s circulatory status is currently stable and does not indicate an adverse reaction to the potassium chloride therapy. Therefore, the nurse does not need to report this specific finding to the healthcare provider.
B. Peaked T-waves are a classic electrocardiographic sign of hyperkalemia, indicating that the potassium replacement therapy may have overcorrected the initial deficit. High serum potassium levels accelerate repolarization, which can quickly transition into dangerous arrhythmias like ventricular fibrillation. This is a critical safety finding that requires immediate notification to the provider to prevent cardiac arrest and adjust the medication.
C. Constipation is a common symptom associated with the initial state of hypokalemia due to decreased smooth muscle motility in the gastrointestinal tract. While the nurse should monitor bowel function, a report of constipation is expected with the underlying diagnosis and is not a priority for reporting. Effective potassium replacement should eventually help restore normal peristalsis and resolve this specific symptom.
D. A blood pressure of 96/80 mm Hg is slightly low but is not the most urgent finding when evaluating the safety of potassium chloride administration. While the nurse should monitor hemodynamics, the immediate threat posed by potassium imbalances is related to cardiac rhythm rather than modest blood pressure fluctuations. Peaked T-waves represent a more direct and fatal complication of electrolyte mismanagement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Sumatriptan is a selective serotonin receptor agonist(triptan) that targets 5-HT1B and 5-HT1D receptors to cause cranial vasoconstriction. It effectively inhibits the release of pro-inflammatory neuropeptidesand suppresses pain transmission within the trigeminal vascular system.
Rationale:
A.Reduction in hand tremors is not a therapeutic effect of sumatriptan, which is specific to migraine pathology. Tremors are usually managed with beta-blockers or dopaminergic agents. Sumatriptan does not influence the motor pathways of the central nervous system or the extrapyramidal system to decrease involuntary muscle movements or tremors in patients.
B.Improved skin condition or the reduction of acne breakouts is unrelated to the pharmacological action of sumatriptan. Triptans do not possess antimicrobial or hormonal properties that would affect the sebaceous glands or integumentary system. This statement would indicate a response to dermatological treatments rather than a medication used for acute migraine relief.
C.The statement that migraine headaches are shorter in duration indicates a therapeutic response, as sumatriptan is used for the acute treatment of migraine attacks. By stimulating serotonin receptors, it reverses the vasodilation and perivascular inflammation responsible for the throbbing pain. Success is measured by the rapid relief of pain and associated symptoms like photophobia.
D.Arthritis pain relief is not an effect of sumatriptan because it is not a general analgesic or anti-inflammatory agent like NSAIDs. Sumatriptan specifically targets receptors found in the cranial blood vessels and has no affinity for peripheral joints or musculoskeletal tissues. It would be ineffective in managing chronic joint inflammation or systemic arthritic pain.
Correct Answer is C
Explanation
Amlodipine is a long-acting dihydropyridine calcium channel blockerthat inhibits the transmembrane influx of calcium ions into vascular smooth muscle. It primarily causes systemic vasodilation, effectively reducing peripheral vascular resistance and lowering arterial blood pressure in hypertensive patients.
Rationale:
A.Oxygen saturation is a measure of hemoglobin oxygen binding and is not directly affected by the administration of calcium channel blockers like amlodipine. While respiratory assessment is part of general nursing care, it is not the priority parameter for a medication that targets vascular resistance. Amlodipine does not interfere with pulmonary gas exchange or the oxygen-carrying capacity of the blood.
B.Heart rate is a critical assessment for non-dihydropyridines like diltiazem, but amlodipine has minimal effect on the sinoatrial or atrioventricular nodes. Because amlodipine is vascular-selective, it does not typically cause the bradycardia associated with other calcium channel blockers. While reflexive tachycardia can occur due to vasodilation, blood pressure remains the most vital parameter to assess prior to dosing this specific agent.
C.Blood pressure must be assessed before administering amlodipine because its primary pharmacological effect is to lower systemic blood pressure through vasodilation. Giving the medication to a patient who is already hypotensive could lead to severe cardiovascular compromise, dizziness, or syncope. The nurse must ensure the client's pressure is within the safe parameters established by the provider to prevent iatrogenic hypotension.
D.Respiratory rate is not influenced by amlodipine, as the drug does not act on the central nervous system respiratory centers or the musculature of the diaphragm. Unlike opioids or certain sedatives, amlodipine does not carry a risk of respiratory depression. Monitoring the breathing rate, while standard, does not provide information relevant to the safety or hemodynamic impact of this antihypertensive medication.
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