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 A
Explanation
Choice A reason : Aspirin is well-known for its antiplatelet properties, which inhibit platelet aggregation and thus prevent the formation of new blood clots. This is particularly important following a myocardial infarction, as it helps to prevent further clotting events that could lead to additional heart attacks or strokes. Aspirin's effect on platelets is so significant that it is often one of the first medications administered in the setting of acute coronary syndrome.
Choice B reason : While aspirin does have analgesic properties, this is not the primary reason it is prescribed post-myocardial infarction. The analgesic effect of aspirin is more commonly utilized for minor pains and aches, and it is not sufficient for the pain associated with coronary artery disease.
Choice C reason : Aspirin can reduce fever, but this is not relevant to its use in coronary artery disease. Fever reduction is not a concern when prescribing aspirin for myocardial infarction patients, as the primary goal is to manage the risk of thrombosis.
Choice D reason : Aspirin does have anti-inflammatory effects, but again, this is not the primary reason for its prescription following a myocardial infarction. While inflammation plays a role in atherosclerosis and coronary artery disease, the anti-inflammatory properties of aspirin are not the main focus in the context of post-myocardial infarction treatment.
Correct Answer is D
Explanation
Choice A reason : The statement that the test will be complete in 30 to 60 minutes is incorrect. An ECG is a quick, non-invasive procedure that typically takes only a few minutes to perform.
Choice B reason : The statement about feeling a slight tingling is not accurate for an ECG. This test does not cause any sensations, as it simply records the electrical activity of the heart.
Choice C reason : The mention of radioactivity from dye is not applicable to an ECG. This test does not involve the use of any dyes or radioactive substances. Dyes are typically used in imaging tests like CT scans or MRIs, not ECGs.
Choice D reason : This is the correct statement. For an ECG, electrodes are placed on the patient's chest and extremities to record the electrical activity of the heart. This allows the healthcare provider to assess the heart's rhythm, identify any irregularities, and diagnose conditions.
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