The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. What should the nurse observe with this electrolyte imbalance?

Prolonged bleeding

Dry mucous membrane

Peaked T-waves

Polyuria

Answer and Explanation

The Correct Answer is C

Choice A reason: Prolonged bleeding is not a direct indicator of hyperkalemia. It is more commonly associated with coagulation disorders or conditions affecting blood clotting.

Choice B reason: Dry mucous membranes are more indicative of dehydration rather than hyperkalemia. Dehydration can result from a variety of conditions but is not specific to high potassium levels.

Choice C reason: Peaked T-waves on an electrocardiogram (ECG) are a classic sign of hyperkalemia. Elevated potassium levels affect the cardiac conduction system, leading to characteristic changes in the ECG, such as tall, peaked T-waves, widened QRS complexes, and flattened P-waves.

Choice D reason: Polyuria (excessive urination) is not typically associated with hyperkalemia. It is more commonly seen in conditions like diabetes mellitus or diabetes insipidus.

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Correct Answer is B

Explanation

Choice A reason: Lying on the side with the head of the bed at 30 degrees may provide some comfort but is not the most effective position for easing breathing in COPD patients. Sitting upright allows for better lung expansion.

Choice B reason: Sitting on the edge of the bed with the arms supported is known as the tripod position. This position helps patients with COPD breathe more easily by allowing the diaphragm to move more freely and reducing the work of breathing.

Choice C reason: Laying in a supine position with arms crossed is not beneficial for COPD patients. This position can restrict lung expansion and make breathing more difficult.

Choice D reason: Sleeping in a prone position with legs elevated is not recommended for COPD patients. It can further restrict breathing and is uncomfortable for patients with respiratory issues.

A. Prepare for the administration of IV fluids B. Administer a bolus of IV fluids C. Administer Atenolol stat D. Administer Nitroglycerin

Correct Answer is B

Explanation

Choice A reason: Preparing for the administration of IV fluids is important but not as immediate as administering a bolus of IV fluids. Immediate fluid resuscitation is crucial for addressing low blood pressure and improving the patient's hemodynamic status.

Choice B reason: Administering a bolus of IV fluids is the priority nursing action for a patient with symptomatic hypotension. Rapid fluid administration helps to increase blood volume and improve blood pressure, which is essential for stabilizing the patient.

Choice C reason: Administering Atenolol, a beta-blocker, is not appropriate for a patient with hypotension. Beta-blockers can further lower blood pressure and are contraindicated in this situation.

Choice D reason: Administering Nitroglycerin is not suitable for a patient with hypotension. Nitroglycerin can cause vasodilation and further decrease blood pressure, which would worsen the patient's condition.

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The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. What should the nurse observe with this electrolyte imbalance?

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Naxlex Comprehensive Predictor Exams

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