A nurse is preparing to administer prescribed intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L (normal range: 3.5 to 5 mEq/L). Which of the following actions should the nurse plan to include? (Select all that apply.)

Ensure that the client's urine output is at least 1 mL/kg/hour.

Educate the client regarding high-potassium food sources.

Cardiac monitoring during infusion.

Repeat blood serum potassium.

Ensure potassium infusion is prepared with 5% dextrose solution.

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: Ensuring the client's urine output is at least 1 mL/kg/hour is important before administering potassium to prevent hyperkalemia, especially in clients with renal impairment.

Choice B reason: While educating the client about high-potassium food sources is important, it is not directly related to the administration of intravenous potassium.

Choice C reason: Cardiac monitoring during infusion is crucial due to the risk of arrhythmias associated with rapid

changes in potassium levels.

Choice D reason: Repeating blood serum potassium is necessary to monitor the effectiveness of the supplementation and avoid hyperkalemia.

Choice E reason: Potassium should not be prepared with 5% dextrose solution as it may cause a trans-cellular shift of potassium into cells, which is not recommended.

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Correct Answer is A

Explanation

Choice A reason: A distended bladder can cause low back pain due to the pressure and stretching of the bladder wall, which is often related to a urinary disorder such as urinary retention or obstruction.

Choice B reason: A stress fracture is less likely to be the cause of low back pain associated with an inability to void and a distended bladder.

Choice C reason: Nerve root pain typically presents with radiating pain down the leg rather than low back pain associated with urinary symptoms.

Choice D reason: Renal cancer could potentially cause low back pain, but it would not typically cause an inability to void or a distended bladder without other significant symptoms.

A. Providing surgical site or wound care B. Managing postoperative pain C. Assisting with early ambulation D. Monitoring urinary function

Correct Answer is D

Explanation

Choice A reason: The nurse is not providing surgical site or wound care by documenting urination.

Choice B reason: Managing postoperative pain is not directly related to monitoring the client's ability to urinate.

Choice C reason: Assisting with early ambulation does not pertain to the urinary function directly.

Choice D reason: Monitoring urinary function is part of postoperative care, especially after removal of a Foley catheter, to ensure the client is able to void normally.

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A nurse is preparing to administer prescribed intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L (normal range: 3.5 to 5 mEq/L). Which of the following actions should the nurse plan to include? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has low back pain reports that they are unable to void. The nurse notices a distended bladder on assessment. Which of the following is the likely cause of this client's low back pain?

Correct Answer is A

Explanation

A nurse removes a client's Foley catheter and documents that the client urinates 4 hours later. Which of the following elements of postoperative care is the nurse performing?

Correct Answer is D

Explanation

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