Adult Health Nursing Flashcards

Which electrolyte imbalance is most commonly associated with prolonged nasogastric suction?

Answer: Hypokalemia and metabolic alkalosis

NG suction removes gastric acid (HCl) and fluids rich in potassium. Loss of hydrogen and chloride ions causes metabolic alkalosis. Continuous loss of gastric contents depletes potassium, causing hypokalemia.

A patient post-thyroidectomy develops tetany and positive Chvostek's sign. Which electrolyte abnormality is most likely?

Answer: Hypocalcemia

The parathyroid glands lie adjacent to the thyroid and may be inadvertently removed or damaged during thyroidectomy. Loss of PTH causes hypocalcemia, manifesting as neuromuscular irritability, tetany, and positive Chvostek's/Trousseau's signs.

Which finding should the nurse report immediately in a patient receiving heparin therapy?

Answer: Sudden back pain and decreased blood pressure

Sudden back pain with hypotension in a heparinized patient suggests retroperitoneal hemorrhage or aortic dissection/hemorrhage — a life-threatening complication. This requires immediate physician notification and possible reversal with protamine sulfate.

A patient's troponin I level is elevated 6 hours after chest pain onset. What does this finding indicate?

Answer: Myocardial cell necrosis consistent with MI

Troponin I is a highly specific cardiac biomarker released when cardiomyocytes die. Elevation 6 hours post-chest pain onset confirms myocardial necrosis (MI). Troponin begins rising 3–4 hours after MI and peaks at 24–48 hours.

Which nursing assessment is most important after administering morphine for post-operative pain?

Answer: Respiratory rate and oxygen saturation

Opioids like morphine cause respiratory depression as their primary serious adverse effect. Monitoring respiratory rate and SpO2 is critical to detect early respiratory compromise. Naloxone (reversal agent) must be immediately available.

A patient has a serum potassium of 6.8 mEq/L. Which ECG change is expected?

Answer: Tall, peaked T waves

Hyperkalemia (K+ >5.5 mEq/L) first causes tall, peaked (tented) T waves. As levels rise further, the PR interval widens, QRS broadens, and eventually a sine-wave pattern and ventricular fibrillation can occur.