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 B

Explanation

A. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation before suctioning is a method to prevent hypoxia, not to thin secretions. It does not affect the viscosity of secretions.

B. Provide humidified oxygen: Humidified oxygen helps to moisten the airways, which can thin secretions, making them easier to clear. This is an appropriate intervention for managing tenacious secretions in a client with a tracheostomy.

C. Perform chest physiotherapy prior to suctioning: Chest physiotherapy helps mobilize secretions but does not thin them. While useful in clearing airways, it is not a direct method for thinning secretions.

D. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: Prelubricating the suction catheter is done to reduce friction and trauma during suctioning but does not impact the thickness of the secretions.

A. Apply positive pressure ventilation and provide supportive care with pain management. B. Perform needle decompression of the pleural space followed by chest tube insertion. C. Administer intravenous antibiotics and arrange for an elective surgical repair. D. Provide high-flow oxygen and intubate the patient for mechanical ventilation.

Correct Answer is B

Explanation

A. Apply positive pressure ventilation and provide supportive care with pain management: While supportive care is important, positive pressure ventilation may not be sufficient to address the underlying issue, which is likely a pneumothorax or hemothorax.
B. Perform needle decompression of the pleural space followed by chest tube insertion: This is the most appropriate initial management for a patient with paradoxical chest wall movement, which is a sign of flail chest and likely pneumothorax. Needle decompression can relieve pressure in the pleural space, and chest tube insertion can help drain any fluid or air that has accumulated.
C. Administer intravenous antibiotics and arrange for an elective surgical repair: While infection may be a concern, it is not the most immediate priority in this case. The patient's respiratory distress needs to be addressed first.
D. Provide high-flow oxygen and intubate the patient for mechanical ventilation: While oxygen therapy may be necessary, intubation should be considered as a last resort if other measures fail to improve oxygenation. In this case, needle decompression and chest tube insertion are more likely to be effective in improving respiratory function.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a tracheostomy and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

Correct Answer is B

Explanation

Exhibits What is the most appropriate initial management for this patient?

Correct Answer is B

Explanation

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