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
Septic shock is characterized by a systemic inflammatory response to infection, leading to vasodilation, increased capillary permeability, and hypotension. The patient’s elevated temperature, tachycardia, and hypotension are consistent with septic shock. In septic shock, the body’s response to infection leads to widespread inflammation and impaired tissue perfusion.
Choice B rationale
Hypovolemic shock is caused by a significant loss of blood or fluids, leading to decreased circulating volume and hypotension. While the patient’s hypotension and tachycardia could be consistent with hypovolemic shock, the elevated temperature suggests an infectious process, making septic shock more likely.
Choice C rationale
Cardiogenic shock is caused by the heart’s inability to pump effectively, leading to decreased cardiac output and tissue perfusion. While hypotension and tachycardia are consistent with cardiogenic shock, the elevated temperature is not a typical finding. Cardiogenic shock is usually associated with conditions like myocardial infarction or severe heart failure.
Choice D rationale
Neurogenic shock is caused by a disruption in the autonomic pathways, leading to vasodilation and hypotension. It is typically associated with spinal cord injuries or severe head trauma. The patient’s elevated temperature and tachycardia are not consistent with neurogenic shock, making septic shock the more likely diagnosis.

A. Increased thirst. B. Increased appetite. C. Slurred speech. D. Polyuria.

Correct Answer is C

Explanation

Choice A rationale
Increased thirst is a symptom of hyperglycemia, not hypoglycemia. It occurs when high blood sugar levels cause dehydration.
Choice B rationale
Increased appetite can occur in hypoglycemia but is not as specific as other symptoms like slurred speech.
Choice C rationale
Slurred speech is a common symptom of hypoglycemia, indicating that the brain is not receiving enough glucose to function properly.
Choice D rationale
Polyuria is a symptom of hyperglycemia, where excess glucose in the blood leads to increased urine production.

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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

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Explanation

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