In reviewing the electrolytes of a patient, the nurse notes the serum potassium level has increased from 4.3 mEq/L to 5.9 mEq/L. Which assessment does the nurse initiate first to prevent further harm?
Oxygen Stats
Pulse rate and Rhythm
Respiratory rate and depth
Deep tendon reflexes
The Correct Answer is B
An increased serum potassium level, also known as hyperkalemia, can have adverse effects on the electrical conduction of the heart, potentially leading to life-threatening cardiac dysrhythmias. Therefore, it is crucial to assess the patient's pulse rate and rhythm promptly to identify any abnormal cardiac activity.
Assessing the oxygen saturation (oxygen stats), respiratory rate and depth, and deep tendon reflexes are also important assessments, but they are not the priority in this case. Hyperkalemia primarily affects cardiac function, and prompt identification of any potential cardiac rhythm disturbances is essential to prevent further harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Gentamicin is an antibiotic that is usually administered via IV infusion. The peak level is the highest concentration of the medication in the bloodstream, and it is important to monitor it to ensure therapeutic levels are achieved without reaching toxic levels.
Drawing the peak level 30 minutes after the infusion is complete allows enough time for the medication to distribute throughout the body and reach its peak concentration. This timing provides an accurate representation of the highest drug concentration in the bloodstream. 30 minutes before starting the infusion: Drawing the peak level before starting the infusion would not accurately reflect the peak concentration of the medication in the bloodstream. Immediately before the next dose of Gentamicin: Drawing the peak level immediately before the next dose would not provide an accurate assessment of the highest drug concentration, as the levels would have started to decrease due to elimination.
1 hour after infusion is complete: Waiting for 1 hour after the infusion is complete may result in missing the actual peak concentration of the medication in the bloodstream, as it may have already started to decline.
Correct Answer is B
Explanation
After rhinoplasty, nasal packing is often used to control bleeding and provide support to the nasal structures. Nasal packing can cause oral dryness, as it obstructs the normal airflow through the nasal passages, leading to mouth breathing. Mouth breathing, in turn, can cause dryness of the oral mucosa and throat, resulting in the sensation of dryness and the need to swallow frequently.
While bleeding is a possible complication after rhinoplasty, the patient's symptom of frequent swallowing is more indicative of oral dryness rather than bleeding.
Although adverse reactions to analgesics can occur, frequent swallowing is not a common symptom associated with analgesic adverse reactions. Other signs such as rash, difficulty breathing, or changes in vital signs would be more typical in case of an adverse reaction. Swallowing can be a normal response to surgery, but in this scenario, the most likely cause is the oral dryness caused by the nasal packing rather than a direct response to the analgesic.
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