A nurse is planning care for a client who has serum potassium of 6.0 mEq/L (Range: 3.5-5.0). Which actions should the nurse anticipate? Select all that apply
Initiate 0.33% sodium chloride IV bolus
Administration of an Ace inhibitor
Administration sodium polystyrene sulfate (kayexalate)
Place the client on a cardiac monitor
Administration of Calcium Gluconate
Correct Answer : C,D,E
A. Initiate 0.33% sodium chloride IV bolus: This is inappropriate as it does not address hyperkalemia and may worsen fluid balance issues.
B. Administration of an ACE inhibitor: ACE inhibitors can increase potassium levels and are contraindicated in hyperkalemia.
C. Administration of sodium polystyrene sulfate (Kayexalate): This medication promotes potassium excretion through the gastrointestinal tract.
D. Place the client on a cardiac monitor: Hyperkalemia affects cardiac function, and continuous monitoring is necessary to detect arrhythmias.
E. Administration of calcium gluconate: Calcium gluconate helps stabilize the cardiac membrane, reducing the risk of arrhythmias from hyperkalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Initiate 0.33% sodium chloride IV bolus: This is inappropriate as it does not address hyperkalemia and may worsen fluid balance issues.
B. Administration of an ACE inhibitor: ACE inhibitors can increase potassium levels and are contraindicated in hyperkalemia.
C. Administration of sodium polystyrene sulfate (Kayexalate): This medication promotes potassium excretion through the gastrointestinal tract.
D. Place the client on a cardiac monitor: Hyperkalemia affects cardiac function, and continuous monitoring is necessary to detect arrhythmias.
E. Administration of calcium gluconate: Calcium gluconate helps stabilize the cardiac membrane, reducing the risk of arrhythmias from hyperkalemia.
Correct Answer is ["B","C","E"]
Explanation
A. Drawing daily labs: This is a clinical task that requires specialized knowledge and skills and should not be delegated to UAP.
B. Transport the urine specimen to the lab: This is a non-clinical task that UAP can perform.
C. Provide perineal care with soap and water around a urinary catheter: UAP can assist with perineal care as it is a routine task that does not require clinical judgment.
D. Insert the foley catheter: Inserting a Foley catheter is a sterile procedure requiring clinical expertise and cannot be delegated to UAP.
E. Assist the incontinent patient to the commode at regular intervals: UAP can assist with toileting and incontinence care.
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