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 ["A","B","C","D","H"]

Explanation

Hematocrit: The client's hematocrit level of 24% is significantly low (normal range: 37% to 47%), indicating anemia. This requires follow-up to determine the underlying cause and initiate appropriate treatment, such as iron supplementation or further investigation.
Oxygen saturation: An oxygen saturation level of 94% is slightly low, especially considering the client's reported shortness of breath. Monitoring is necessary to ensure adequate oxygenation and to assess if supplemental oxygen or further respiratory evaluation is needed.
Activity level: The client reports generalized weakness and increased fatigue, particularly becoming short of breath after minimal exertion (e.g., climbing stairs). This decreased activity level is concerning and may indicate cardiovascular or hematological issues, requiring further assessment and follow-up.
Blood pressure: The blood pressure readings indicate orthostatic hypotension, with a drop from 118/60 mm Hg sitting to 102/50 mm Hg standing. This significant drop suggests potential volume depletion or anemia, which requires follow-up to assess fluid status and ensure safety during ambulation.
Vitamin B12 level: The Vitamin B12 level of 159 pg/mL is slightly below the normal range (160 to 950 pg/mL), indicating potential deficiency. This can lead to anemia and neurological issues. Follow-up is needed to evaluate dietary intake and consider supplementation.

Temperature: The client's temperature of 37° C (98.6° F) is within normal limits and does not indicate a need for follow-up. Monitoring for signs of infection or inflammation is important, but this finding is stable.
Breath sounds: The assessment shows clear and present bilateral breath sounds, which indicate no respiratory distress or abnormalities. This finding does not require follow-up.
Pain level: The client reports no pain or discomfort, which is a positive finding and does not necessitate further follow-up. Ongoing assessment for pain should continue, but current findings are stable.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Infection: Poor glycemic control, indicated by an elevated hemoglobin A1c of 9.5%, leads to impaired immune function, delayed wound healing, and increased risk of postoperative infections. Chronic hyperglycemia promotes bacterial growth, reduces leukocyte function, and compromises vascular integrity, further predisposing the client to infections.
Deep vein thrombosis (DVT): Postoperative immobility, increased coagulation, and endothelial injury increase DVT risk. However, BUN of 15 mg/dL is within the normal range and does not indicate dehydration or hemoconcentration, which would contribute to thrombus formation.
Hypovolemia: Reduced blood volume typically presents with signs such as hypotension, tachycardia, and elevated BUN/creatinine ratio. Preoperative hypertension does not indicate hypovolemia and is more commonly associated with chronic vascular resistance rather than acute fluid loss.
BUN of 15 mg/dL: A BUN level within the normal range does not suggest an increased risk for DVT or fluid imbalance. It primarily reflects renal function and hydration status, neither of which are significantly altered in this case.
Preoperative hypertension: While chronic hypertension is a cardiovascular risk factor, it does not indicate hypovolemia, which would present with dehydration-related signs such as orthostatic hypotension, tachycardia, and decreased urine output.
Hemoglobin A1c: A value of 9.5% indicates poor long-term glycemic control, which impairs immune function and slows wound healing. Elevated glucose levels reduce neutrophil function, impair macrophage activity, and increase oxidative stress, all of which contribute to a heightened infection risk.

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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?

Nursing Test Bank

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Explanation

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