How it Works
Try Naxlex NCLEX-RN (Free-Trial)

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. What should the nurse assess before administering the medications

A.

Blood glucose

B.

Level of consciousness (LOC)

C.

Bowel sounds

D.

Blood urea nitrogen (BUN)

Answer and Explanation

The Correct Answer is C

A. Blood glucose: Monitoring blood glucose is important for patients receiving insulin and dextrose as treatment for hyperkalemia, but it is not directly related to sodium polystyrene sulfonate. Kayexalate works in the GI tract and does not typically affect glucose levels.

B. Level of consciousness (LOC): Assessing LOC is always essential for safety, but it is not the priority before giving Kayexalate. The drug’s mechanism of action requires bowel function, so neurological status is not the most relevant factor in this situation.

C. Bowel sounds: Kayexalate exchanges sodium for potassium in the colon and requires an intact, functioning bowel to be effective and safe. Absent bowel sounds may indicate ileus or obstruction, and giving the drug in this condition can cause severe complications such as intestinal necrosis.

D. Blood urea nitrogen (BUN): BUN helps monitor renal function and fluid balance, but it does not determine the safety of Kayexalate administration. Although kidney disease may contribute to hyperkalemia, bowel function is the most critical assessment before giving this medication.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

A. Apply absorbent adult incontinence diapers and pads over the bed linens: Absorbent products may help keep the skin dry, but it does not address the patient’s continence needs or promote independence. Prolonged use also increases risk of skin breakdown and infection.

B. Assist the patient to the bathroom every 2 hours during the day: Scheduled toileting supports continence, reduces the risk of falls, and promotes dignity. It also helps prevent skin complications from incontinence and reduces the likelihood of urinary tract infections.

C. Restrict fluids between meals and after the evening meal: Fluid restriction is not appropriate in dehydration, as the patient needs fluid replacement to restore balance. Limiting fluids could worsen confusion, impair perfusion, and further elevate the risk of complications

D. Insert an indwelling catheter until the symptoms have resolved: Indwelling catheters increase the risk of urinary tract infections, especially in older adults. Catheterization should be avoided unless absolutely necessary for close monitoring of urine output or in cases of urinary obstruction.

Correct Answer is D

Explanation

A. Demonstrate how to perform the Crede maneuver: The Crede maneuver involves applying manual pressure over the bladder to aid emptying and is typically used for patients with neurogenic bladder or urinary retention, not stress incontinence.

B. Assist the patient to the bathroom every 3 hr: Scheduled toileting may help reduce urgency episodes or functional incontinence, but it does not address the pelvic floor weakness that causes leakage during laughing or coughing in stress incontinence.

C. Place a commode at the patient’s bedside: A bedside commode may be useful for patients with mobility issues or urgency incontinence. In stress incontinence, leakage occurs with increased intra-abdominal pressure rather than inability to reach the toilet quickly.

D. Teach the patient how to perform Kegel exercises: Kegel exercises strengthen pelvic floor muscles, improving urethral sphincter control and reducing leakage episodes during activities like coughing, sneezing, or laughing.

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

Register