The nurse is reviewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L and Potassium 6.6 mEq/L. Which of the following should be the priority intervention?
Request a CT scan of the head.
Assess for Chvostek’s sign.
Obtain a chest X-ray.
Obtain a 12-lead ECG.
The Correct Answer is D
A. A CT scan of the head is not indicated based on the laboratory findings provided. The priority intervention is related to the elevated potassium level.
B. Chvostek’s sign is associated with hypocalcemia (low calcium levels), not hyperkalemia (high potassium levels).
C. A chest X-ray is not the priority intervention for elevated potassium. The primary concern is the potential for cardiac arrhythmias related to the high potassium level.
D. Hyperkalemia (potassium 6.6 mEq/L) can lead to cardiac arrhythmias. The nurse should obtain a 12-lead ECG to assess for any changes in the heart's electrical activity, which could indicate serious complications like arrhythmias or cardiac arrest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administering furosemide (a diuretic) would worsen dehydration and is contraindicated in this scenario. The goal is to rehydrate the client, not to promote fluid loss.
B. Educating the client that oral fluids are not necessary is incorrect. Oral fluids are important for rehydration, and the client should be encouraged to drink fluids unless contraindicated.
C. Monitoring the client's weight once a week is not sufficient for assessing dehydration status. More frequent monitoring is needed to assess the effectiveness of treatment.
D. Monitoring the client's IV site and infusion is essential to ensure that the IV is patent, the fluid is being infused properly, and there are no complications such as infiltration or infection. This is a key aspect of nursing care for clients receiving IV fluids.
Correct Answer is D
Explanation
A. An inverted P wave is not typically associated with hypokalemia but may indicate other conduction abnormalities such as atrial ectopic rhythms.
B. A wide QRS complex is more commonly associated with hyperkalemia rather than hypokalemia. It may also indicate other conduction delays or ventricular issues.
C. An elevated ST segment suggests myocardial injury or pericarditis, not hypokalemia.
D. A flattened T wave is a hallmark of hypokalemia. Low potassium levels affect the repolarization phase of the cardiac cycle, leading to T wave flattening or inversion and, in severe cases, the presence of a U wave.
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