A nurse is reviewing laboratory values of a client with chronic renal failure and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?
Administering sodium polystyrene sulfonate.
Initiating an IV potassium infusion.
Administering a potassium-sparing diuretic.
Encouraging the client to eat bananas.
The Correct Answer is A
A. Administering sodium polystyrene sulfonate:
This medication removes potassium through the GI tract and is used to treat hyperkalemia.
B. Initiating an IV potassium infusion:
The client already has hyperkalemia; giving potassium would worsen it.
C. Administering a potassium-sparing diuretic:
These medications retain potassium and would further elevate potassium levels.
D. Encouraging the client to eat bananas:
Bananas are high in potassium and should be avoided in hyperkalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is ["A","D","E"]
Explanation
A. Blistering of area: Blisters are characteristic of superficial partial-thickness burns, involving the epidermis and part of the dermis.
B. Dry crusting surface: This is more typical of deeper burns; partial-thickness burns are moist.
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D. Blanching of wound area: Indicates intact capillary refill and superficial depth.
E. Pain at wound site: Nerve endings are exposed, making these burns very painful.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Critical to assess: A. Airway patency and signs of inhalation injury
Clients in enclosed-space fires are at high risk for inhalation injury, which can lead to airway edema and obstruction. This is the first priority.
Critical assessment finding: C. Singed nasal hairs and soot around the nares
These are hallmark signs of possible inhalation injury and may indicate airway compromise even before symptoms become severe.
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