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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A barrel chest is typically not associated with mitral valve stenosis. It is more commonly seen in chronic obstructive pulmonary disease (COPD) due to hyperinflation of the lungs. Mitral valve stenosis affects the heart and not the lung structure.
Choice B reason: Clubbing of the fingers is a sign that can be associated with chronic hypoxia and certain types of congenital heart disease. While it can be seen in some heart conditions, it is not a specific finding for mitral valve stenosis.
Choice C reason: A heart murmur, specifically a diastolic murmur, is a classic finding in mitral valve stenosis. As the stenotic mitral valve obstructs blood flow from the left atrium to the left ventricle, a pressure gradient is created, which produces a murmur that can be heard upon auscultation.
Choice D reason: Bradycardia, or a slower than normal heart rate, is not a direct finding associated with mitral valve stenosis. Mitral valve stenosis may lead to arrhythmias such as atrial fibrillation due to atrial enlargement, but bradycardia is not typically induced by this condition.
Correct Answer is D
Explanation
Choice A reason : Applying ice to the extremity is not a standard intervention for DVT. Ice is typically used to reduce inflammation and pain, but in the case of DVT, the priority is to prevent the clot from growing and embolizing. The use of warmth, not cold, may be recommended to help reduce discomfort and swelling.
Choice B reason : Administering vasodilating medications is not a typical intervention for DVT. Vasodilators are used to widen blood vessels and improve blood flow, but they do not address the risk of clot formation or embolization associated with DVT. The mainstay of medical treatment for DVT is anticoagulant therapy, which helps to prevent further clotting.
Choice C reason : Restricting oral fluids is not an intervention for DVT. Adequate hydration is important in the management of DVT as it can help to prevent blood from thickening and reduce the risk of further clot formation. There is no indication to restrict fluids unless there is another underlying condition that requires it.
Choice D reason : Monitoring platelet levels is an important intervention in the care of a client with DVT, especially if they are receiving anticoagulant therapy. Anticoagulants can affect platelet function and count, and monitoring is necessary to ensure safe levels and prevent complications such as bleeding or thrombocytopenia.
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