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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Hematuria is not a typical finding after peritoneal dialysis, although it can occur in some clients with kidney disease.

B. Weight loss is not expected after dialysis; it is more likely to stabilize fluid balance and remove excess fluid.

C. Hypertension can be expected in clients with chronic kidney disease, as the kidneys play a key role in regulating blood pressure.

D. Increased urine output is not typically seen in clients with chronic kidney disease, especially after dialysis.

A. This occurred because there was an obstruction of urine flow from the kidneys B. This occurs because there was a decrease in blood flow to the kidneys C. This occurred because there was structural damage to the kidneys resulting in acute tubular necrosis D. This occurred because a blood cat formed in the kidneys

Correct Answer is B

Explanation

A. Obstruction of urine flow can lead to prerenal or postrenal acute kidney injury, but hypovolemic shock is a cause of decreased blood flow to the kidneys, not obstruction.

B. Hypovolemic shock leads to decreased blood flow to the kidneys, which can cause acute renal failure. This is the most appropriate cause of acute renal failure in the context of hypovolemic shock.

C. Acute tubular necrosis is a result of prolonged ischemia or direct kidney injury and may follow decreased blood flow, but the primary cause in this case is hypovolemic shock.

D. A blood clot in the kidneys may cause acute renal failure but is not the typical cause in hypovolemic shock.

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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

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Naxlex Comprehensive Predictor Exams

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