A nurse is caring for a client who is experiencing acute kidney failure after a surgical procedure. Telemetry monitoring shows a widened QRS, frequent premature ventricular contractions, and a heart rate of 55/min. Which of the following electrolyte imbalances should the nurse identify?
Hyperkalemia.
Hypocalcemia.
Hyperglycemia.
Hypophosphatemia.
The Correct Answer is A
Choice A rationale:
The combination of widened QRS, frequent premature ventricular contractions (PVCs), and bradycardia (heart rate of 55/min) on telemetry monitoring suggests hyperkalemia. Elevated potassium levels in the blood can cause delayed repolarization of cardiac cells, leading to widened QRS complexes and PVCs. Bradycardia is another common manifestation of hyperkalemia.
Choice B rationale:
Hypocalcemia, characterized by low calcium levels in the blood, can lead to cardiac arrhythmias, but it typically presents with a prolonged QT interval rather than widened QRS complexes and PVCs.
Choice C rationale:
Hyperglycemia, which is high blood glucose levels, does not directly affect the electrocardiogram (ECG) parameters like QRS width or heart rate. It may have systemic effects, but it is not responsible for the ECG changes described in the scenario.
Choice D rationale:
Hypophosphatemia, or low levels of phosphate in the blood, can cause muscle weakness and may have systemic effects, but it is not associated with the specific ECG changes seen in hyperkalemia, such as widened QRS complexes and PVCs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Covering bedside water pitchers after being filled helps reduce the risk of contamination and infection by preventing the entry of airborne pathogens or debris.
Choice B rationale:
Allowing dressings that get wet in the shower to dry out is not an effective infection control strategy. Wet dressings can become a breeding ground for bacteria, and it is important to change wet dressings promptly to minimize the risk of infection.
Choice C rationale:
Used needles should be immediately disposed of in sharps containers, not placed at the nurses' station. Placing used needles in the sharps container promptly helps prevent accidental needlestick injuries and potential transmission of infections.
Choice D rationale:
Drainage bottles should be emptied regularly to prevent overfilling, but they should not be allowed to become full. Regular emptying ensures proper functioning and reduces the risk of spillage or contamination in the client care area.
Correct Answer is B
Explanation
Choice A rationale:
A capillary refill of less than 1 second is a normal finding and indicates adequate peripheral perfusion. It is not a cause for concern in this postoperative client.
Choice B rationale:
The presence of a pulse deficit should be reported to the provider because it suggests a discrepancy between the apical and radial pulses, indicating potential cardiovascular compromise or inadequate arterial perfusion.
Choice C rationale:
A systolic blood pressure 10 points lower than before surgery can be a normal response to anesthesia or surgery and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.
Choice D rationale:
Pulse oximetry at 96% is within the normal range for oxygen saturation and does not warrant immediate reporting. However, if the client is experiencing respiratory distress or other concerning symptoms, it should be addressed promptly.
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