A nurse cares for a patient who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which should the nurse implement first?
Provide a heart healthy low potassium diet
Prepare to administer sodium polystyrene sulfate 15g by mouth
Prepare the patient for hemodialysis treatment
Prepare to administer dextrose 20% and 10 units of regular insulin IV push
The Correct Answer is D
A. Provide a heart-healthy low-potassium diet:
While a heart-healthy low-potassium diet is essential for managing chronic hyperkalemia and preventing future occurrences, it is not the first intervention to implement in a patient with a serum potassium level of 7.5 mEq/L and exhibiting cardiovascular changes. The effects of dietary changes on serum potassium levels are gradual and may take days to have a significant impact. In an acute situation like this, immediate interventions are needed to rapidly lower potassium levels and address the associated cardiovascular risks.
B. Prepare to administer sodium polystyrene sulfate 15g by mouth:
Sodium polystyrene sulfate is a medication used to exchange sodium for potassium in the gastrointestinal tract, effectively lowering serum potassium levels over hours to days. While it is a valid treatment for hyperkalemia, its onset of action is not immediate enough to address the urgent cardiovascular changes seen in severe hyperkalemia. Therefore, it is not the first-line intervention in this scenario.
C. Prepare the patient for hemodialysis treatment:
Hemodialysis is an effective method for rapidly lowering serum potassium levels in cases of severe hyperkalemia. However, it is a more invasive and time-consuming procedure that requires preparation, including vascular access and dialysis setup. It is typically reserved for situations where other interventions have failed or in patients with severe or refractory hyperkalemia. In the context of this scenario, where the patient has a serum potassium level of 7.5 mEq/L and is exhibiting cardiovascular changes, hemodialysis may be considered if initial interventions are not successful, but it is not the first action to implement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
This response is the best choice because it educates the client about the potential for deeper tissue damage associated with electrical burns. It acknowledges that while the burn on the skin may appear small, the damage underneath could be more extensive, affecting muscles, nerves, and blood vessels.
B. Electrical burns commonly cause reddened/purplish skin without blistering.
This statement is not the best response because it focuses solely on the appearance of the skin without addressing the potential for deeper tissue damage. While it is true that electrical burns can present with reddened or purplish skin without blistering, this response does not provide comprehensive information about the nature and severity of electrical burns.
C. Electrical burns typically are minor.
This response is incorrect because it downplays the seriousness of electrical burns. While some electrical burns may indeed be minor, others can cause significant tissue damage and complications. It's important for the nurse to educate the client about the range of severity that electrical burns can present.
D. Electrical burns usually cause much more skin damage than what can be seen on your skin.
This statement is partially accurate but does not provide as much information as choice A. While it acknowledges that electrical burns can cause more damage than what is visible on the skin's surface, it doesn't emphasize the potential for deeper tissue damage as effectively as choice A does.

Correct Answer is D
Explanation
A. Evidence-based practice:
Evidence-based practice (EBP) involves integrating the best available evidence from research, clinical expertise, and patient preferences and values to inform nursing practice. In perioperative nursing, EBP is important for making informed decisions about preoperative, intraoperative, and postoperative care protocols. For example, using evidence-based guidelines for surgical site infection prevention, pain management strategies, and postoperative care protocols can improve patient outcomes and safety.
B. Informatics:
Informatics refers to the use of information technology and data management systems to support nursing practice, education, research, and patient care. In perioperative nursing, informatics plays a crucial role in managing electronic health records (EHRs), accessing patient data, documenting care, and communicating with interdisciplinary team members. It also includes utilizing perioperative information systems for surgical scheduling, anesthesia records, and tracking patient progress during surgery.
C. Quality improvement:
Quality improvement (QI) involves systematic processes to monitor, assess, and improve the quality of healthcare services. In perioperative nursing, QI initiatives focus on enhancing patient safety, optimizing surgical outcomes, reducing complications, and improving efficiency in perioperative processes. Nurses participate in QI projects by analyzing data, identifying areas for improvement, implementing evidence-based practices, and evaluating the impact of interventions on patient care and outcomes.
D. Safety:
Safety is a fundamental QSEN competency, particularly critical in perioperative nursing care. Perioperative nurses are responsible for ensuring the safety of patients during all phases of surgery, including preoperative assessment, intraoperative care, and postoperative recovery. This includes measures such as verifying patient identity and surgical site, preventing surgical errors (e.g., wrong-site surgery), maintaining aseptic techniques to prevent infections, preventing falls and injuries, managing anesthesia safely, and adhering to protocols for safe medication administration and equipment use.
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