A nurse is caring for a client with chronic kidney disease (CKD) who presents with hyperkalemia. Which of the following interventions should the nurse implement first?

Administer sodium polystyrene sulfonate as prescribed.

Monitor the client’s cardiac rhythm.

Restrict dietary potassium intake.

Prepare the client for hemodialysis.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Administering sodium polystyrene sulfonate helps to lower potassium levels by exchanging sodium ions for potassium ions in the intestines. However, it is not the first intervention because it takes time to work and does not address the immediate risk of cardiac arrhythmias caused by hyperkalemia.
Choice B rationale
Monitoring the client’s cardiac rhythm is the first intervention because hyperkalemia can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these arrhythmias, which is crucial for the client’s safety.
Choice C rationale
Restricting dietary potassium intake is an important long-term management strategy for hyperkalemia, especially in clients with chronic kidney disease. However, it does not address the immediate risk of cardiac arrhythmias and is not the first intervention.
Choice D rationale
Preparing the client for hemodialysis is a definitive treatment for hyperkalemia, especially in clients with chronic kidney disease. However, it is not the first intervention because it takes time to arrange and initiate dialysis. Immediate cardiac monitoring is necessary to manage the acute risk of arrhythmias.

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Correct Answer is A

Explanation

Choice A rationale
Severe headache and photophobia are classic symptoms of meningitis, indicating inflammation of the meninges.
Choice B rationale
Chest pain and shortness of breath are more indicative of cardiovascular or respiratory issues, not meningitis.
Choice C rationale
Abdominal pain and diarrhea are gastrointestinal symptoms and are not typically associated with meningitis.
Choice D rationale
Joint pain and swelling are more indicative of rheumatologic conditions, not meningitis.

A. It takes about 14 days to develop antibodies and immunity to the disease after vaccine administration. B. The laboratory ran out of blood specimen tubes and is unable to perform the test today. C. It takes about 14 days to develop antigens and immunity to the disease after vaccine administration. D. After receiving the vaccine, you might transmit the communicable disease to the laboratory.

Correct Answer is A

Explanation

Choice A rationale
It takes about 14 days to develop antibodies and immunity to the disease after vaccine administration. This is why the patient is asked to return in 2 to 3 weeks for an antibody titer. The immune system needs time to respond to the vaccine and produce detectable levels of antibodies.
Choice B rationale
The laboratory running out of blood specimen tubes is not a valid reason for delaying the antibody titer. This choice does not provide an accurate explanation for the patient.
Choice C rationale
It takes about 14 days to develop antibodies, not antigens, and immunity to the disease after vaccine administration. This choice contains incorrect information about the immune response.
Choice D rationale
After receiving the vaccine, the patient is not likely to transmit the communicable disease to the laboratory. This choice does not provide a valid reason for delaying the antibody titer.

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A nurse is caring for a client with chronic kidney disease (CKD) who presents with hyperkalemia. Which of the following interventions should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with suspected meningitis. Which of the following symptoms would most likely indicate meningitis?

Correct Answer is A

Explanation

After receiving a vaccination for a communicable disease, the patient was asked to return in 2 to 3 weeks to get an antibody titer and asks why blood testing can’t be done immediately.How should the RN (registered nurse) respond?

Correct Answer is A

Explanation

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