A nurse receives a laboratory report for a client indicating an elevated potassium (K+) level.
When notifying the provider, the nurse should expect to perform which of the following actions first?
Initiation of cardiac monitoring.
Consulting with the dietician to decrease the intake of foods with potassium.
Instruct the client to avoid bananas.
Initiation of IV fluids.
The Correct Answer is A
Choice A rationale
An elevated potassium level (hyperkalemia), defined as serum potassium >5.0 mEq/L, can cause severe cardiac excitability changes, leading to peaked T waves, a widened QRS complex, and potentially life-threatening ventricular dysrhythmias, such as ventricular fibrillation. Initiating continuous cardiac monitoring is the most immediate priority action to promptly detect and manage these dangerous electrical instability changes.
Choice B rationale
Consulting with a dietician to adjust the diet is a non-pharmacological, long-term intervention for managing hyperkalemia. While essential for sustained management, this action does not address the immediate, life-threatening risk of cardiac dysrhythmias associated with an acute, elevated potassium level and is therefore not the first priority.
Choice C rationale
Instructing the client to avoid high-potassium foods like bananas is a component of dietary management, which is a key part of long-term care but not the immediate priority. Acute hyperkalemia requires prompt interventions to shift potassium back into cells or promote its excretion to protect the heart. The normal range for serum potassium is 3.5 to 5.0 mEq/L.
Choice D rationale
Initiation of IV fluids alone (like normal saline) is generally not the primary or most effective initial treatment for hyperkalemia. While sometimes used in conjunction with loop diuretics, definitive urgent treatment involves giving calcium gluconate to stabilize the myocardium, and then insulin/dextrose or albuterol to shift potassium into cells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.5"]
Explanation
Step 1 is 25 mg ÷ (50 mg ÷ 5 mL).
Step 2 is 25 mg ÷ 10 mg/mL.
Step 3 is 2.5 mL. The nurse should administer 2.5 mL. .
Correct Answer is A
Explanation
Choice A rationale
Left-sided heart failure impairs the left ventricle's ability to effectively pump oxygenated blood forward into the systemic circulation. This causes blood to back up into the left atrium and subsequently into the pulmonary veins and capillaries, resulting in increased pulmonary pressure. Fluid then leaks into the alveoli, causing the classic sound of pulmonary crackles (rales).
Choice B rationale
Jugular vein distension (JVD) is a cardinal sign of increased pressure in the systemic venous circulation, indicating right-sided heart failure. When the right ventricle fails, blood backs up into the right atrium and then into the great veins, causing distension and visibility of the internal and external jugular veins in the neck.
Choice C rationale
Dependent edema, which is swelling in the lower extremities, is a typical manifestation of right-sided heart failure. The inability of the right ventricle to manage systemic venous return causes blood to pool in the peripheral veins, leading to increased hydrostatic pressure that forces fluid out of the capillaries into the interstitial tissue.
Choice D rationale
Nocturnal polyuria, or increased urination at night, is a common symptom in heart failure but is more directly related to the movement of pooled dependent edema fluid (from the legs/feet) back into the central circulation when the client lies down. This increases renal blood flow and diuresis, but is not exclusively an assessment finding for left-sided failure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.