The nurse is caring for the client with cardiac and renal disease. The client now has a serum potassium level of 6.0 mEq/L. Which medications, if prescribed, should the nurse administer? Select all that apply.
Calcium gluconate 1.5 grams IV now
Dextrose 50% injection (50ml) IV push now
Colace 100 mg PO now
Regular insulin 10 units IV now
Potassium chloride 20 mEq orally now
Correct Answer : A,B,D
A) Calcium gluconate 1.5 grams IV now: Calcium gluconate is administered to counteract the effects of hyperkalemia by stabilizing the myocardial cell membrane. It does not lower potassium levels but helps protect the heart from potential dysrhythmias associated with high potassium levels.
B) Dextrose 50% injection (50ml) IV push now: Dextrose 50% injection, also known as D50W, is administered to temporarily shift potassium from the extracellular space into the intracellular space, thereby lowering serum potassium levels. It is commonly used in combination with insulin to facilitate the movement of potassium into cells.
C) Colace 100 mg PO now: Colace is a stool softener and does not affect serum potassium levels. It is not indicated for the treatment of hyperkalemia.
D) Regular insulin 10 units IV now: Regular insulin is administered with dextrose to facilitate the movement of potassium from the extracellular space into the intracellular space. Insulin stimulates the cellular uptake of glucose, which in turn drives potassium into cells along with glucose.
E) Potassium chloride 20 mEq orally now: Potassium chloride is contraindicated in the treatment of hyperkalemia as it would further increase serum potassium levels. It is typically used to supplement potassium in clients with hypokalemia, not hyperkalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Severity
In the PQRST mnemonic for pain assessment, "S" stands for Severity. When the nurse asks the client to rate the pain on a scale of 0 to 10, they are assessing the severity of the pain. This helps the nurse understand the intensity of the client's pain experience and provides a baseline for evaluating the effectiveness of pain management interventions.
B. Precipitating cause
This component relates to factors that exacerbate or alleviate the pain and is represented by the "P" in the PQRST mnemonic. Asking about activities or events that preceded the onset of pain helps identify potential triggers or causes.
C. Region
The "R" in PQRST represents Region, referring to the specific location or area where the client experiences pain. Assessing the region helps localize the source of pain and guide further diagnostic evaluations or interventions.
D. Quality
Quality, represented by the "Q" in PQRST, refers to the characteristics or nature of the pain, such as sharp, dull, throbbing, or burning. Understanding the quality of pain provides additional information about its underlying cause and can aid in selecting appropriate treatment strategies.
Correct Answer is C
Explanation
A. Helping the client select a low-salt diet:
This option is not directly related to addressing tenacious bronchial secretions in COPD. While a low-salt diet may be beneficial for managing conditions like hypertension or heart failure, it does not directly influence the viscosity of bronchial secretions.
B. Administering oxygen via nasal cannula at 2 L/min:
Oxygen therapy is important for clients with COPD, especially during exacerbations or periods of hypoxemia. However, in this scenario, the client's primary concern is tenacious bronchial secretions, and oxygen therapy alone may not effectively address this issue.
C. Encouraging the client to drink 2 to 3 L of water daily:
This is the correct answer. Increasing fluid intake helps to hydrate the mucous membranes and thin bronchial secretions, making them easier to expectorate. Adequate hydration is essential for optimizing the clearance of secretions in clients with COPD.
D. Maintaining a semi-Fowler's position as often as possible:
While maintaining a semi-Fowler's position can improve respiratory mechanics and reduce dyspnea in clients with COPD, it does not directly address the issue of tenacious bronchial secretions. This position primarily helps in optimizing lung expansion and facilitating easier breathing.
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