The K laboratory report shows a level of 5.2 mEq/L (Normal 3.5-5.0 mEq/L). What is the most important assessment for the nurse to make?
Excessive thirst
Irregular heartbeat
Swelling of ankles
Frightening hallucinations
The Correct Answer is B
A. Excessive thirst: Excessive thirst, polydipsia, is not the most immediate concern with a potassium level of 5.2 mEq/L. Potassium levels within this range (slightly elevated) may not directly cause excessive thirst.
B. Irregular heartbeat: Elevated potassium levels can cause dangerous cardiac arrhythmias, including irregular heartbeat. Therefore, the most important assessment is monitoring for signs of cardiac disturbances.
C. Swelling of ankles: Swelling of the ankles is more commonly associated with fluid retention or circulatory issues and is not directly linked to minor elevations in potassium levels. Although elevated potassium can affect fluid balance, it does not immediately present as swelling.
D. Frightening hallucinations: Hallucinations can be caused by a variety of factors, but they are not a direct effect of slightly elevated potassium levels. More serious symptoms like cardiac arrhythmias are a more immediate concern with abnormal potassium levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An NG tube to suction: Nasogastric (NG) tube suction can result in the loss of potassium through gastric secretions. Prolonged suction can cause a significant loss of electrolytes, including potassium, leading to hypokalemia. This is the client most at risk for hypokalemia.
B. An indwelling urinary catheter to gravity drainage: An indwelling urinary catheter drains urine, which does not typically cause significant potassium loss. Potassium loss through the urinary system would require excessive urination or diuretic use, not gravity drainage.
C. A chest tube to water-seal drainage: A chest tube to water-seal drainage is used to drain air or fluid from the pleural space. It does not typically result in significant electrolyte loss like potassium, so this is not a major concern for hypokalemia.
D. A nephrostomy tube to a drainage bag: A nephrostomy tube drains urine from the kidney, but it does not generally lead to significant potassium loss unless there are other underlying conditions, such as diuretic therapy. This is not as high a risk for hypokalemia as NG suction.
Correct Answer is B
Explanation
A. Elevated serum calcium and potassium levels: Hypomagnesemia typically causes decreased calcium levels, not elevated. Additionally, while magnesium helps maintain potassium levels, hypomagnesemia can lead to a drop in potassium, not an elevation.
B. Decreased serum calcium and potassium levels: Hypomagnesemia often leads to low calcium levels due to decreased parathyroid hormone secretion and can cause hypokalemia due to impaired potassium uptake in the kidneys.
C. Impaired acid-base balance: Hypomagnesemia itself does not cause significant acid-base imbalance. It’s more likely to cause electrolyte disturbances especially calcium and potassium, which can lead to arrhythmias, acid-base imbalance is not the primary concern.
D. Bradycardia and cardiac dysrhythmias: While hypomagnesemia can indeed cause cardiac dysrhythmias, a common manifestation is tachycardia rapid heart rate and certain types of arrhythmias like Torsades de Pointes, rather than bradycardia.
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