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

Explanation

A. "Eat a light meal 1 hour before bedtime.": Eating before bedtime increases the risk of acid reflux because lying down soon after eating allows stomach contents to flow back into the esophagus. It is recommended to avoid eating at least 2 to 3 hours before lying down.

B. "Lie down for 30 minutes after each meal.": Lying down after meals promotes reflux by reducing the effect of gravity in keeping stomach contents in place. Instead, clients should remain upright for at least 2 hours after eating to minimize symptoms.

C. "Sleep with the head of your bed elevated 6 inches.": Elevating the head of the bed helps prevent stomach acid from flowing back into the esophagus by using gravity to reduce reflux symptoms. This is a well-established lifestyle modification for GERD management.

D. "Increase your caloric intake by 250 calories per day.": Increasing caloric intake is not a recommended intervention for GERD. Excess weight can worsen symptoms by increasing intra-abdominal pressure, so weight management is often advised for clients with GERD.

A. "Use the incentive spirometer every 4 hours." B. "Avoid coughing during and after the session." C. "Remove the mouthpiece and exhale quickly." D. "Place the mouthpiece in your mouth and inhale slowly."

Correct Answer is D

Explanation

A. "Use the incentive spirometer every 4 hours.": Incentive spirometry is typically recommended every 1 to 2 hours while awake to promote lung expansion and prevent atelectasis. Less frequent use may not provide adequate lung re-expansion, especially after surgery.

B. "Avoid coughing during and after the session.": Coughing is encouraged after using an incentive spirometer to help clear secretions and prevent respiratory complications such as pneumonia. Suppressing a cough can lead to mucus retention and increased risk of infection.

C. "Remove the mouthpiece and exhale quickly.": The client should exhale normally before using the spirometer, then inhale slowly through the mouthpiece to maximize lung expansion. Rapid exhalation does not promote adequate alveolar inflation.

D. "Place the mouthpiece in your mouth and inhale slowly.": Slow, deep inhalation through the spirometer allows for maximum lung expansion, reducing the risk of atelectasis. The client should maintain a steady breath to ensure optimal lung inflation and hold it for a few seconds before exhaling.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

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