A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Electrocardiogram (ECG) results. When a patient taking spironolactone presents with a high serum potassium level of 6 mEq/L, the nurse's priority should be to assess the patient's ECG results. Hyperkalemia, indicated by elevated potassium levels, can lead to life-threatening cardiac arrhythmias, making cardiac monitoring crucial. Option A) Neuromuscular function is important in assessing electrolyte imbalances, but in this case, the priority is the potential cardiac impact of hyperkalemia. Option B) Bowel sounds are not the priority when dealing with hyperkalemia; while altered bowel function can occur, it is not an immediate concern. Option C) Respiratory rate is crucial in many situations, but in this case, the focus should be on the cardiac implications of high potassium levels. Educationally, understanding the priority assessments in patients with electrolyte imbalances is essential for nurses caring for patients on medications like spironolactone. This knowledge helps ensure timely interventions to prevent serious complications related to electrolyte disturbances, particularly in patients with cardiac comorbidities.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Hypokalemia. Hypokalemia refers to low levels of potassium in the blood, which can cause symptoms such as weakness, irregular pulse, and disorientation. The patient is taking hydrochlorothiazide, a diuretic that commonly causes potassium loss through increased urinary excretion. This medication can lead to electrolyte imbalances, specifically hypokalemia. Option A) Hypernatremia is unlikely in this case because the symptoms presented are not consistent with high sodium levels. Hypernatremia typically presents with symptoms such as thirst, dry mucous membranes, and restlessness. Option B) Hyponatremia is also less likely as it presents with symptoms like headache, confusion, seizures, and possibly coma. The symptoms of the patient in the scenario do not align with those of hyponatremia. Option C) Hyperkalemia is not the correct answer because the patient's symptoms are more indicative of low potassium levels rather than high potassium levels. Hyperkalemia usually presents with muscle weakness, cardiac arrhythmias, and potentially cardiac arrest. Understanding electrolyte imbalances is crucial in medical-surgical nursing as they can have significant impacts on a patient's health. It is essential for nurses to recognize the signs and symptoms of various electrolyte imbalances, understand the medications that can contribute to these imbalances, and be prepared to intervene appropriately to restore electrolyte balance and prevent complications.

Correct Answer: C

Rationale: Furosemide is a potassium-wasting diuretic. A low potassium level may cause weakness and palpitations. Telling the patient to rest more often won't help the patient if she's hypokalemic. Digoxin isn't causing the patient's symptoms, so she doesn't need to stop taking it. The patient should probably avoid caffeine, but this wouldn't resolve potassium depletion.

Correct Answer: B

Rationale: Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. The number of dissolved particles contained in a unit of fluid determines the osmolality of a solution, which influences the movement of fluid between the fluid compartments. Giving a patient who has a low blood pressure a hypertonic solution will increase the number of dissolved particles in the blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Option A is incorrect; hydrostatic pressure refers to changes in water or volume related to water pressure. Option C is incorrect; diffusion is the movement of solutes from an area of greater concentration to lesser concentration. The solutes in an intact vascular system are unable to move, so diffusion should not normally take place. Option D is incorrect; active transport is the movement of molecules against the concentration gradient and requires ATP as an energy source. This process typically takes place at the cellular level and is not involved in vascular volume changes.

Correct Answer: D

Rationale: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely cause of the lower urine output.