A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?

Have the laboratory draw a blood sample for an erythrocyte sedimentation rate

Obtain a 12-lead ECG

Administer potassium gluconate 40 mEq orally

Restrict fluid intake

Answer and Explanation

The Correct Answer is B

Choice A reason : An erythrocyte sedimentation rate (ESR) test is not directly related to high serum potassium levels and would not be the immediate action in response to hyperkalemia.

Choice B reason : Obtaining a 12-lead ECG is a critical step when hyperkalemia is suspected because high potassium levels can cause life-threatening cardiac arrhythmias. An ECG can quickly reveal characteristic changes associated with hyperkalemia, allowing for prompt treatment.

Choice C reason : Administering potassium gluconate would be contraindicated in a patient with hyperkalemia, as it would further increase the serum potassium levels, potentially leading to severe complications.

Choice D reason : Restricting fluid intake is not a standard treatment for hyperkalemia. The management of hyperkalemia may include medications or procedures that promote the excretion of potassium or move potassium from the blood into the cells.

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Correct Answer is D

Explanation

Choice A reason : Morphine is an opioid analgesic used to relieve severe pain and can be administered to patients with myocardial infarction to alleviate chest pain and anxiety. However, it is not the first medication given as it does not address the underlying cause of the myocardial infarction, which is the formation of a blood clot in the coronary arteries.

Choice B reason : Nitroglycerin is a nitrate that helps to dilate blood vessels and improve blood flow. It can be used to relieve chest pain in myocardial infarction, but similar to morphine, it is not the initial medication of choice. The priority is to prevent further blood clotting.

Choice C reason : Administered as soon as possible to inhibit platelet aggregation and reduce clot progression.

Choice D reason : When a myocardial infarction (MI) is suspected, the priority is to address tissue hypoxia and ensure adequate oxygenation to minimize myocardial damage. Administering oxygen helps increase oxygen availability to the ischemic heart tissue, reducing further damage.

A. Check the level of the client's pain. B. Check the client's blood pressure. C. Check the client's bowel sounds. D. Check the client's catheter insertion site.

Correct Answer is A

Explanation

Choice A reason: Pain assessment is a critical priority for postoperative patients. After aortic valve replacement surgery, patients may experience discomfort or pain related to the incision site, chest tube placement, or other surgical interventions. Pain assessment allows the nurse to evaluate the effectiveness of pain management strategies, adjust medications as needed, and ensure the patient's comfort and well-being. Pain can also impact vital signs and overall recovery, so addressing it promptly is essential.

Choice B reason: Monitoring blood pressure is important, but it is not the highest priority immediately after surgery. Blood pressure assessment is part of routine postoperative care, but it does not directly address the patient's immediate comfort or potential complications. However, if the patient's blood pressure becomes significantly abnormal, it would require immediate attention.

Choice C reason: Checking bowel sounds is relevant for assessing gastrointestinal function, but it is not the top priority immediately postoperatively. Bowel sounds may be diminished initially due to anesthesia, surgical manipulation, or bowel rest. However, assessing pain and other vital signs takes precedence over bowel sounds in the immediate recovery period.

Choice D reason: Assessing the catheter insertion site is essential, especially if the patient has an indwelling urinary catheter. However, it is not the highest priority immediately after aortic valve replacement. Pain assessment and monitoring for complications related to surgery (such as bleeding, infection, or cardiac issues) take precedence. The catheter site can be assessed during routine nursing care.

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A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who has a suspected myocardial infarction. Which of the following medications should the nurse plan to administer first?

Correct Answer is D

Explanation

A nurse is collecting data on a patient who is postoperative following aortic valve replacement. Which of the following tasks should the nurse prioritize during data collection?

Correct Answer is A

Explanation

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