A nurse is caring for a client who is receiving potassium chloride 40 mEq IV every 4 hr. Which of the following findings indicate the client is becoming hyperkalemic?

Hypoactive bowel sounds

Sinus rhythm with peaked T waves

Irritability and anxiety

Shallow respirations

Answer and Explanation

The Correct Answer is B

A. Hypoactive bowel sounds: Hyperkalemia typically causes increased gastrointestinal motility, leading to hyperactive bowel sounds and diarrhea rather than hypoactive bowel sounds.

B. Sinus rhythm with peaked T waves: Elevated potassium levels affect cardiac conduction, leading to ECG changes such as peaked T waves, prolonged PR intervals, and widened QRS complexes. These findings indicate early hyperkalemia and require immediate attention.

C. Irritability and anxiety: While hyperkalemia can cause neuromuscular symptoms, such as muscle weakness and paresthesia, irritability and anxiety are more commonly associated with hypoglycemia or hypoxia rather than hyperkalemia.

D. Shallow respirations: Severe hyperkalemia can lead to muscle weakness, including respiratory muscles, but this occurs in later stages. Shallow respirations are more commonly associated with conditions like respiratory depression or metabolic alkalosis.

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Correct Answer is ["C","D","E"]

Explanation

A. Born with a high birth weight: Hearing loss is more commonly associated with low birth weight rather than high birth weight. Premature infants or those with complications like neonatal hypoxia are at a greater risk of auditory damage due to underdeveloped structures and increased vulnerability to infections.

B. Frequent exposure to low-volume noise: Prolonged exposure to loud noise, not low-volume noise, is a significant risk factor for hearing loss. High-decibel sounds can cause permanent damage to the cochlear hair cells, leading to sensorineural hearing loss, especially in occupational or recreational settings.

C. Use of a loop diuretic: Loop diuretics like furosemide can be ototoxic, especially when administered in high doses or given too rapidly through IV. They can cause reversible or permanent hearing loss by damaging the stria vascularis of the cochlea, which affects inner ear fluid balance.

D. Chronic infections of the middle ear: Recurrent otitis media can lead to chronic inflammation, scarring, or ossicle damage, resulting in conductive hearing loss. Long-term infections may also cause cholesteatoma formation, which can further impair hearing by destroying middle ear structures.

E. Perforation of the eardrum: Tympanic membrane rupture due to infections, trauma, or barotrauma can lead to conductive hearing loss by impairing sound transmission. While small perforations may heal spontaneously, larger tears might require surgical repair to restore normal hearing function.

A. 150 mL of greenish yellow NG drainage B. Client requests medication for nausea C. Urinary output of 250 mL over past 12 hr D. Hypoactive bowel sounds

Correct Answer is C

Explanation

A. 150 mL of greenish yellow NG drainage: This amount and color of drainage are expected after abdominal surgery, as bile-stained gastric contents can be present. It does not indicate a complication that requires provider notification.

B. Client requests medication for nausea: Nausea is a common postoperative symptom, often managed with antiemetics. While it should be addressed, it is not an urgent finding that requires immediate provider notification.

C. Urinary output of 250 mL over past 12 hr: Oliguria, defined as urine output less than 30 mL/hr (or less than 400 mL in 24 hr), suggests inadequate renal perfusion, possibly due to hypovolemia or acute kidney injury. This finding requires prompt provider notification.

D. Hypoactive bowel sounds: Reduced bowel activity is common after abdominal surgery due to anesthesia and opioid use. While monitoring is necessary, hypoactive sounds alone are not an urgent concern unless accompanied by other signs of ileus or obstruction.

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A nurse is caring for a client who is receiving potassium chloride 40 mEq IV every 4 hr. Which of the following findings indicate the client is becoming hyperkalemic?

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