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 C

Explanation

A. Hepatitis does not involve costovertebral pain and is unrelated to calcium supplementation.
B. Pancreatitis typically presents with abdominal pain, not costovertebral pain.
C. Renal stones (kidney stones) are a possible adverse effect of excess calcium intake and can cause costovertebral pain due to their location.
D. A hip fracture is associated with osteoporosis, but it does not present as costovertebral pain.

A. Ensure the drainage tubing is patent and without obstruction. B. Notify the surgeon if the urine is bright red in appearance or has large clots. C. Add the amount of bladder irrigation to the total output. D. Use sterile technique when preparing the irrigation solution. E. Contact the surgeon if the client reports a continual need to void.

Correct Answer is ["A","B","D","E"]

Explanation

A. Patency of the drainage tubing is crucial to prevent blockage and maintain continuous flow.
B. Bright red urine or large clots could indicate bleeding, requiring immediate notification of the surgeon.
C. The amount of irrigation fluid is usually subtracted from the total output to determine true urine output, not added.
D. Using sterile technique helps prevent infection in a postoperative patient.
E. A continual urge to void could indicate bladder spasms or improper catheter placement, and the surgeon should be contacted.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has osteoporosis and takes a daily calcium supplement. Which of the following adverse effects of calcium should the nurse suspect when the client reports having costovertebral pain?

Correct Answer is C

Explanation

A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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