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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increased urinary frequency can be a symptom but is more common in early stages or with benign prostatic hyperplasia.
B. Erectile dysfunction may occur but is not as specific to advanced prostate cancer.
C. Severe hematuria is not commonly associated with advanced prostate cancer.
D. Bone pain and fractures are common in advanced stages due to metastasis, particularly to the bones.
Correct Answer is ["2"]
Explanation
To administer a dose of 650 mg of aspirin when only 325 mg tablets are available, the nurse would need to give two tablets to meet the required dose. Each tablet contains 325 mg, so two tablets would equal 650 mg, which is the desired dose to be administered every 12 hours.
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