A patient presents with a heart rate of 130 beats/minute and a blood pressure of 82/66 after exerting themselves in the sun. Which of the following interventions would be most appropriate?

Administer a hypotonic solution

Administer a vasoconstrictor medication

Administer an isotonic solution intravenously

Administer a hypertonic solution intravenously

Answer and Explanation

The Correct Answer is C

A. Administering a hypotonic solution would not be appropriate in this case. Hypotonic solutions can lower the blood pressure further and worsen the patient’s condition.
B. Administering a vasoconstrictor medication may increase blood pressure, but it is not the first-line treatment for dehydration or volume loss, which seems to be the cause of the patient’s symptoms.
C. Administering an isotonic solution intravenously is the most appropriate intervention. The patient is likely experiencing dehydration and hypotension due to fluid loss from exertion in the sun (possibly heat exhaustion). Isotonic fluids such as normal saline or lactated Ringer's solution are typically used to restore circulating volume and improve blood pressure.
D. Administering a hypertonic solution would be inappropriate, as it could increase the osmolarity of the blood and worsen dehydration, potentially causing fluid shifts that could lead to complications such as cellular dehydration.

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Correct Answer is B

Explanation

A. Administration of IV antibiotics is not appropriate for this client, as there is no indication of an infection. The client's symptoms are consistent with fluid overload due to heart failure, not an infectious process.
B. Administration of IV diuretics is the priority intervention. The client is exhibiting signs of fluid overload, including jugular venous distention, crackles, and a bounding pulse. IV diuretics, such as furosemide, help reduce fluid volume, alleviate pulmonary congestion, and improve breathing.
C. Isotonic intravenous fluids would exacerbate the fluid overload and worsen the client's symptoms. This intervention is contraindicated in this scenario.
D. Laying the client supine with legs elevated is inappropriate for a client with heart failure and fluid overload, as it can increase venous return to the heart and worsen pulmonary congestion. Instead, the client should be positioned upright to improve breathing.

A. Advise the client to add citrus juices and bananas to their diet. B. Obtain a 12-lead ECG. C. Obtain a blood sample for a serum sodium level. D. Suggest that the client use a salt substitute.

Correct Answer is B

Explanation

A. Advising the client to add citrus juices and bananas is inappropriate because these are high in potassium and would further increase the already elevated potassium level, potentially worsening hyperkalemia.
B. Obtaining a 12-lead ECG is the correct action. A potassium level of 6.8 mEq/L is critically high and can cause life-threatening cardiac arrhythmias. An ECG can help identify hyperkalemia-related changes, such as peaked T waves, widened QRS complexes, or arrhythmias.
C. While obtaining a serum sodium level might provide additional information, it does not address the immediate risk posed by the elevated potassium level. The priority is assessing the cardiac effects of hyperkalemia.
D. Suggesting that the client use a salt substitute is incorrect, as many salt substitutes contain potassium chloride, which could worsen hyperkalemia.

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A patient presents with a heart rate of 130 beats/minute and a blood pressure of 82/66 after exerting themselves in the sun. Which of the following interventions would be most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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