The patient's potassium level is 6.2 mEq/L. Which of the following signs should the nurse monitor most closely?
Blood pressure changes
Electrocardiogram abnormalities
Respiratory rate
Level of consciousness
The Correct Answer is B
A. Blood pressure changes are incorrect because although hyperkalemia can indirectly affect cardiac output, blood pressure is not the most sensitive indicator of elevated potassium. Blood pressure may remain normal even when dangerous arrhythmias are developing.
B. Electrocardiogram abnormalities is correct because hyperkalemia directly affects cardiac conduction. At a potassium level of 6.2 mEq/L, patients are at high risk for life-threatening arrhythmias. Typical ECG changes include peaked T waves, prolonged PR interval, widened QRS complex, flattened P waves, and a sine wave pattern, which may progress to ventricular fibrillation or asystole. Continuous cardiac monitoring is essential because these changes can occur rapidly, and early detection allows immediate intervention to prevent cardiac arrest.
C. Respiratory rate is incorrect because hyperkalemia typically does not initially affect respiration. Severe hyperkalemia can lead to muscle weakness, including the diaphragm, which may reduce ventilation, but these complications occur after cardiac effects and are not the most urgent concern.
D. Level of consciousness is incorrect because neurological changes such as confusion, weakness, or paresthesia are usually late signs of hyperkalemia. While important to monitor, altered mental status is less immediately life-threatening than cardiac effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Irregular respirations is incorrect because irregular or abnormal breathing patterns, such as Cheyne-Stokes or ataxic respirations, are part of Cushing’s triad. These occur due to pressure on the brainstem and impaired respiratory control.
B. Fever is correct because fever is not a component of Cushing’s triad. While fever may occur in neurological injury due to hypothalamic dysfunction or infection, it is not a defining feature of the triad. Including fever as part of the triad would be incorrect.
C. Bradycardia is incorrect because a slowed heart rateis a classic component of Cushing’s triad. It develops as a compensatory response to increased intracranial pressure and rising systolic blood pressure.
D. Increased systolic blood pressure is incorrect because hypertension with widened pulse pressureis another hallmark of Cushing’s triad. This occurs as a compensatory mechanism to maintain cerebral perfusion in the setting of elevated ICP.
Correct Answer is B
Explanation
A. That the patient will be alert and oriented is incorrect because a GCS of 8 indicates severe impairment of consciousness, not alertness. Patients who are alert and oriented typically have a GCS of 13–15.
B. The patient will be comatose is correct because a GCS score of 8 or lessis generally considered coma or severe brain injury. This indicates significant neurological impairment, and the patient is likely unable to respond appropriately to verbal or painful stimuli. Immediate interventions often focus on airway protection, stabilization, and rapid neurological assessment.
C. The patient will likely have a UTI is incorrect because a urinary tract infection is not related to the GCS score. While a UTI can cause confusion in older adults, it does not directly correlate with a GCS of 8 in trauma or acute neurological events.
D. That the patient will be vomiting is incorrect because vomiting may occur in patients with elevated intracranial pressure or head trauma, but it is not a defining feature of a GCS of 8. The key concern is level of consciousnessand neurological status.
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