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A nurse is caring for a client who is receiving parenteral nutrition and identifies that the client has hyperkalemia. Which of the following actions should the nurse take?

Warm formula to room temperature.

Place the client on a cardiac monitor.

Administer IV dextrose.

Request a lactose-free formula.

Answer and Explanation

The Correct Answer is B

A. Warming the formula to room temperature would not address hyperkalemia.

B. Hyperkalemia can lead to cardiac dysrhythmias, so placing the client on a cardiac monitor

allows for continuous cardiac monitoring to detect any changes or abnormalities in heart rhythm.

C. Administering IV dextrose is not typically indicated for hyperkalemia. Instead, insulin may be administered with dextrose to promote cellular uptake of potassium.
D. Requesting a lactose-free formula is not relevant to the management of hyperkalemia.

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Correct Answer is A

Explanation

A. Filing a report with the facility to document the incident as a near miss medication error is essential for tracking and investigating medication errors to prevent future occurrences.
B. While contacting the prescribing provider may be necessary, the priority is to report the error internally within the facility.
C. While documenting the nurse's actions is important, it is essential to report the error through the appropriate channels within the facility.
D. While informing the client about the error is necessary, the immediate action should be to report the error internally within the facility.

A. “Use a nasal decongestant 15 minutes before the medication if you have a stuffy nose." B. "Plan to self-administer this medication for the next 6 months." C. "Lie down for 1 hour after administering the medication." D. "Administer the medication into one nostril once per week."

Correct Answer is D

Explanation

A. “Use a nasal decongestant 15 minutes before the medication if you have a stuffy nose": This statement is not necessary for the administration of nasal cyanocobalamin. Nasal decongestants are not routinely recommended before administering nasal medications.
B. "Plan to self-administer this medication for the next 6 months": While the duration of treatment for pernicious anemia may vary, specifying a timeframe of 6 months for self- administration is not appropriate without considering individualized treatment plans.

C. "Lie down for 1 hour after administering the medication": There is no need for the client to lie down after administering nasal cyanocobalamin. This instruction is not necessary and may not be practical.
D. "Administer the medication into one nostril once per week": This is the correct instruction for administering nasal cyanocobalamin. It is typically given once weekly into one nostril. This
method provides a convenient and effective route for vitamin B12 supplementation in clients with pernicious anemia.

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A nurse is caring for a client who is receiving parenteral nutrition and identifies that the client has hyperkalemia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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