The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?
Reference Range:
Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
Obtain a 12-lead electrocardiogram daily.
Evaluate glucose levels before and after meals.
Monitor and document strict intake and output.
Assess the serum potassium level every 4 hours.
The Correct Answer is D
Choice A reason: While obtaining a 12-lead electrocardiogram is important for monitoring cardiac function, it is not as frequent or specific as potassium monitoring for hyperkalemia management.
Choice B reason: Evaluating glucose levels is necessary due to the risk of hypoglycemia from insulin administration, but the priority is monitoring potassium levels in hyperkalemia.
Choice C reason: Monitoring intake and output is part of fluid balance management but is secondary to the critical need to monitor serum potassium levels.
Choice D reason: Frequent assessment of serum potassium levels is essential to evaluate the effectiveness of the dextrose and insulin therapy in lowering potassium levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Suggesting that delirium is often a sign of underlying mental illness and that institutionalization is necessary can be distressing and may not be accurate without further assessment.
Choice B reason: Stating that dementia due to Alzheimer's disease is often reversible even in the late stages is incorrect; Alzheimer's disease is a progressive condition with no current cure.
Choice C reason: Recognizing the possibility of delirium due to depression, which can be reversible, is a hopeful and constructive approach that encourages further evaluation and treatment options.
Choice D reason: Suggesting that symptoms of dementia are permanent because of age can be disheartening and does not consider the potential for reversible causes of cognitive impairment.
Correct Answer is C
Explanation
The correct answer is: c. Inspiratory and expiratory bilateral crackles.
Choice A: Average urine output of 28 mL/hour
Reason: The normal urine output for an adult is typically 0.5 mL/kg/hr, which translates to about 30-50 mL/hr for most adults. An average urine output of 28 mL/hour is slightly below this range, indicating possible inadequate fluid resuscitation. However, it is not immediately life-threatening and does not warrant the most urgent intervention compared to other options.
Choice B: Vesicular bibasilar breath sounds
Reason: Vesicular breath sounds are normal lung sounds heard over most of the lung fields. They are soft and low-pitched, indicating that the airways are clear. Therefore, vesicular bibasilar breath sounds do not indicate any immediate respiratory distress or fluid overload and do not require urgent intervention.
Choice C: Inspiratory and expiratory bilateral crackles
Reason: Crackles, also known as rales, are abnormal lung sounds that indicate the presence of fluid in the alveoli. Bilateral crackles heard during both inspiration and expiration suggest significant pulmonary edema or acute respiratory distress syndrome (ARDS), which can be life-threatening and requires immediate intervention.
Choice D: Central venous pressure of 12 mm Hg
Reason: The normal range for central venous pressure (CVP) is 2-8 mm Hg. A CVP of 12 mm Hg is elevated, indicating possible fluid overload or heart failure. While this is concerning and requires monitoring, it is not as immediately critical as bilateral crackles, which directly affect oxygenation and respiratory function.
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