A nurse is assisting with preparations for administering intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L. Which of the following actions should the nurse plan to include? (Select all that apply.)

Repeat blood serum potassium

Educate client regarding high-potassium food sources

Cardiac monitoring during infusion

Ensure that the client's urine output is at least 1 mL/kg/hour

Ensure potassium infusion is prepared with 5% dextrose solution

Answer and Explanation

Correct Answer : C,D

A. Repeat blood serum potassium: While it’s important to monitor potassium levels, the immediate priority when preparing to administer potassium is ensuring safe administration practices, not rechecking levels before initiating therapy.

B. Educate client regarding high-potassium food sources: Client education is important for long-term management but is not a priority when preparing for intravenous potassium replacement in an acute setting.

C. Cardiac monitoring during infusion: Potassium affects cardiac conduction, and rapid correction can lead to arrhythmias. Continuous cardiac monitoring is necessary to detect any life-threatening arrhythmias during the infusion.

D. Ensure that the client's urine output is at least 1 mL/kg/hour: Adequate urine output ensures that the kidneys are functioning and capable of excreting excess potassium, reducing the risk of hyperkalemia.

E. Ensure potassium infusion is prepared with 5% dextrose solution: Potassium should not be mixed with dextrose, as it can increase insulin release, causing potassium to shift into cells and worsen hypokalemia.

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Correct Answer is A

Explanation

A. Expiratory wheeze: Wheezing, particularly on expiration, is a characteristic finding during an acute asthma exacerbation. It occurs due to the narrowing of the airways and turbulent airflow.

B. Rhonchi: Rhonchi are low-pitched, rattling sounds often caused by secretions in larger airways, not typically associated with asthma exacerbations.

C. Pleural friction rub: A pleural friction rub is a grating sound heard when the pleurae are inflamed, often seen in conditions like pleuritis, not asthma.

D. Fine rales: Fine rales, or crackles, are associated with fluid in the alveoli, often found in conditions like pneumonia or heart failure, rather than asthma

A. The client has developed confusion. B. The client's serum sodium is 140 mEq/L (135 to 145 mEq/L). C. The client has a positive Chvostek's sign. D. The client's blood urea nitrogen (BUN) level is 18 mg/dL (10 to 20 mg/dL).

Correct Answer is A

Explanation

A. The client has developed confusion: Hypotonic fluids can cause a rapid shift of water into cells, potentially leading to cerebral edema. This can manifest as confusion or altered mental status, which is a serious adverse effect requiring immediate attention.

B. The client's serum sodium is 140 mEq/L (135 to 145 mEq/L): A serum sodium level within the normal range indicates that the hypotonic fluid therapy is likely effective in correcting hypernatremia, and does not suggest an adverse effect.

C. The client has a positive Chvostek's sign: A positive Chvostek's sign is indicative of hypocalcemia rather than an adverse effect of hypotonic fluid administration. This sign is related to low calcium levels and is not a direct result of hypotonic fluid therapy.

D. The client's blood urea nitrogen (BUN) level is 18 mg/dL (10 to 20 mg/dL): This BUN level is within normal limits and does not suggest an adverse effect of hypotonic fluid therapy. BUN levels can be affected by various factors, but this value alone is not indicative of an adverse reaction.

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A nurse is assisting with preparations for administering intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L. Which of the following actions should the nurse plan to include? (Select all that apply.)

Nursing Test Bank

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A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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