A nurse is reviewing the EKG strip of a client who has End Stage Renal Disease (ESRD) and has missed hemodialysis. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hyperkalemia?
Prolonged P-R interval
Peaked T waves
Elevated ST segment
Inverted P wave
The Correct Answer is B
A. Prolonged P-R interval: A prolonged P-R interval may indicate an atrioventricular (AV) block or conduction delay, but it is not specifically associated with hyperkalemia.
B. Peaked T waves: Peaked T waves are a classic EKG finding in hyperkalemia. Hyperkalemia can affect cardiac repolarization, leading to tall, peaked T waves on the EKG.
C. Elevated ST segment: An elevated ST segment may indicate myocardial injury or ischemia but is not typically associated with hyperkalemia.
D. Inverted P wave: An inverted P wave may indicate atrial enlargement or conduction abnormalities but is not specifically associated with hyperkalemia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
The nurse should first place the client in high Fowler's position to ease the breathing and improve oxygenation, as the client is experiencing increased dyspnea and chest pain. This position allows for better lung expansion and can be a critical immediate intervention. Following this, the nurse should obtain IV access to facilitate the administration of medications and fluids as needed. IV access is essential for the rapid administration of potential treatments, including anticoagulants, which may be required if a pulmonary embolism is confirmed. These actions are prioritized to address the client's immediate respiratory distress and to prepare for further interventions based on the evolving clinical situation. It is important to note that each clinical scenario is unique, and the interventions should be tailored to the client's specific needs and the healthcare provider's clinical judgment.
Correct Answer is B
Explanation
A. Respond to ventilator alarms: Responding to ventilator alarms is important but may not be the priority if the client is not spontaneously breathing.
B. Report the absence of spontaneous respirations: This is the priority action because the absence of spontaneous respirations may indicate inadequate ventilation or respiratory arrest, requiring immediate intervention.
C. Encourage the client to take spontaneous breaths: While encouraging spontaneous breaths is beneficial, it is not appropriate if the client is paralyzed due to neuromuscular blockade.
D. Place the call bell within reach: Ensuring the call bell is within reach is important for communication but may not be the priority if the client is not breathing spontaneously.
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