Medical Surgical Potassium K+ #11

Question

A client taking spironolactone is demonstrating electrocardiogram changes and muscle weakness. For which electrolyte imbalance would the nurse plan interventions?

Answers

  1. Hyperkalemia
    • Rationale:

      This answer is correct because spironolactone is a potassium-sparing diuretic, which will raise the potassium levels within the blood. If the client is demonstrating ECG changes and muscle weakness, it is possible that the potassium level is elevated indicating a need to plan interventions to address hyperkalemia to enhance client safety.

  2. Hypercalcemia
    • Rationale:

      This answer is not correct because spironolactone is not known to cause alterations in serum calcium levels; therefore, it is not necessary for the nurse to plan interventions to address hypercalcemia.

  3. Hypocalcemia
    • Rationale:

      This answer is not correct because spironolactone is not known to cause alterations in serum calcium levels; therefore, it is not necessary for the nurse to plan interventions to address hypocalcemia.

  4. Hypokalemia
    • Rationale:

      This answer is not correct because spironolactone is a potassium-sparing diuretic, so it is unlikely the client is experiencing hypokalemia. Loop diuretics, such as furosemide, place the client at risk for hypokalemia.

Overview

An electrolyte imbalance is defined as an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis.

Explanation

Learning Outcomes

Electrolytes play a vital role in maintaining homeostasis. They help to regulate acid-base and fluid balance, cardiac and neurological function, and oxygen delivery. Clients who are prescribed diuretics, such as spironolactone, are at risk for increased levels of potassium in the blood as this diuretic is potassium-sparing. This coupled with the electrocardiogram changes and muscle weakness, both manifestations of hyperkalemia, indicate a need to plan interventions to address this specific electrolyte imbalance.

Test Taking Tip

Consider the impact that spironolactone has on electrolyte levels in the client’s blood to answer this question correctly.

Video Rationale