A patient is transferred to the emergency department from the outpatient clinic with a diagnosis of hyperkalemia. Kayexalate was prescribed. Which of the following nursing actions will the nurse perform before administering Kayexalate?

Start IV 0.9% Sodium Chloride

Assess for bowel sounds

Start 02 at 2L/min

Assess lab value for potassium

Answer and Explanation

The Correct Answer is B

A. Starting IV 0.9% sodium chloride may be necessary for hydration but is not a priority action before administering Kayexalate.
B. Assessing for bowel sounds is essential because Kayexalate works by exchanging potassium for sodium in the intestine, and bowel motility must be adequate to ensure the medication is effective and to prevent complications such as bowel obstruction.
C. Starting oxygen is unnecessary unless the patient exhibits signs of respiratory distress, which is not indicated here.
D. While checking potassium levels is important, it is often done as part of the initial assessment and does not need to be repeated immediately before administering Kayexalate if levels were already assessed and are high.

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Correct Answer is B

Explanation

A. PaO2 below 70 mm Hg may indicate hypoxemia, not necessarily metabolic acidosis.
B. A pH below 7.35 is indicative of acidosis, supporting a diagnosis of metabolic acidosis if other findings align.
C. An elevated PaCO2 suggests respiratory acidosis, not metabolic acidosis.
D. HCO3 above 26 mEq/L suggests metabolic alkalosis; in metabolic acidosis, HCO3 is typically low.

A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

Correct Answer is A

Explanation

A. Respiratory acidosis occurs due to hypoventilation, which causes an accumulation of carbon dioxide in the blood, leading to increased acidity. Shallow respirations at a rate of 8 breaths per minute indicate hypoventilation, putting the client at risk for respiratory acidosis.
B. Metabolic acidosis is typically caused by metabolic issues such as kidney failure or diabetic ketoacidosis, not by respiratory changes.
C. Respiratory alkalosis results from hyperventilation, which leads to a decrease in carbon dioxide levels, causing alkalinity in the blood.
D. Metabolic alkalosis is caused by factors such as prolonged vomiting or diuretic use, not by hypoventilation.

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A patient is transferred to the emergency department from the outpatient clinic with a diagnosis of hyperkalemia. Kayexalate was prescribed. Which of the following nursing actions will the nurse perform before administering Kayexalate?

Nursing Test Bank

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