A nurse is caring for a client with a current blood potassium level of 5.4 mEq/L (3.5-5 mEq/L). Which finding would this client have?
Constipation
Polyuria
EKG with a U wave
Paresthesias of the extremities
The Correct Answer is D
A) Constipation: Elevated potassium levels (hyperkalemia) typically affect neuromuscular and cardiac function rather than gastrointestinal motility. Constipation is more commonly associated with conditions like hypokalemia or electrolyte imbalances affecting the gastrointestinal system.
B) Polyuria: Polyuria, or excessive urination, is not directly caused by hyperkalemia. It can occur due to conditions like diabetes mellitus or diabetes insipidus, or as a side effect of certain medications like diuretics. Hyperkalemia does not typically lead to increased urine output and may even lead to oliguria if severe renal impairment occurs.
C) EKG with a U wave: The presence of a U wave on an electrocardiogram (EKG) is typically associated with hypokalemia, not hyperkalemia. U waves are seen when potassium levels are low, reflecting delayed repolarization of the ventricles. In hyperkalemia, EKG changes more commonly include peaked T waves, prolonged PR interval, and widened QRS complexes.
D) Paresthesias of the extremities: Hyperkalemia can cause paresthesias, which are sensations of tingling or numbness, particularly in the extremities. This occurs due to the effect of elevated potassium levels on nerve and muscle function. As potassium is essential for maintaining normal neuromuscular function, deviations from normal levels can disrupt action potentials and lead to sensory disturbances like paresthesias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) The first 2 min: While it is essential to monitor the client closely during the first few minutes of a PRBC infusion, a two-minute observation period is insufficient to detect most acute transfusion reactions. Many reactions, such as fever, chills, and allergic responses, can take longer to manifest.
B) The final 15 min: Monitoring during the final 15 minutes is important to ensure the infusion is completed without complications. However, the most critical time for monitoring is at the beginning of the infusion, as acute reactions are more likely to occur early on.
C) The first 15 min: The first 15 minutes of a PRBC transfusion are crucial because most acute transfusion reactions, such as allergic reactions, febrile non-hemolytic reactions, and hemolytic reactions, occur within this time frame. The nurse should remain at the bedside to promptly identify and manage any adverse reactions, ensuring the client's safety.
D) The final 2 min: Monitoring during the final two minutes of the infusion is also important, but it is not the critical time frame for detecting most transfusion reactions. Observing the client closely during the initial phase of the transfusion is essential to address any immediate complications.
Correct Answer is C
Explanation
A) Discontinue cardiac monitoring during the infusion:
Discontinuing cardiac monitoring during the infusion of potassium chloride is unsafe. Potassium infusions can significantly impact cardiac function, so continuous cardiac monitoring is necessary to detect any arrhythmias or other complications.
B) Administer KCI as a rapid IV bolus:
Administering potassium chloride as a rapid IV bolus is contraindicated due to the risk of severe adverse effects, including cardiac arrest. Potassium should be infused slowly to avoid complications.
C) Only give the KCI via a central venous line:
Potassium chloride is ideally administered through a central venous line because it is irritating to veins and can cause damage if given through a peripheral line. A central line reduces the risk of irritation and allows for safer infusion of potassium.
D) Infuse the KCI at a rate of 10 mEq/hour:
Infusing potassium chloride at a rate of 10 mEq/hour is generally too slow for an emergency situation requiring immediate correction of severe hypokalemia. For more urgent cases, higher rates may be required, but only under strict medical supervision to avoid complications.
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