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 {"dropdown-group-1":"D","dropdown-group-2":"D"}
Explanation
The rationale for identifying the client as at risk for hypoxia is based on the respiratory assessment findings. Diminished lung sounds in the posterior lobes suggest reduced air movement or potential complications such as atelectasis or pneumonia, which can impair gas exchange. Additionally, the decreased oxygen saturation of 84% on room air indicates inadequate oxygenation of the blood. Hypoxia occurs when there is insufficient oxygen supply to tissues, which can lead to serious complications if not addressed promptly. Therefore, recognizing these respiratory assessment findings is crucial for identifying the risk of hypoxia in the client.
Correct Answer is B
Explanation
A. Placing the soiled linen on the floor before bagging it is unsanitary and violates infection control principles. It increases the risk of spreading pathogens to other surfaces, potentially contaminating the environment.
B. Placing clean linen that touched the floor in the soiled linen bag prevents cross-contamination and maintains cleanliness. It adheres to infection control standards by ensuring that only soiled items are disposed of appropriately.
C. Holding the soiled linen against her body while carrying it to the linen bag risks transferring pathogens to the caregiver's clothing and skin, compromising personal hygiene and promoting contamination.
D. Shaking the soiled linen to remove any toilet paper remnants is ineffective and hazardous. It disperses potentially infectious particles, increasing the risk of contamination and compromising infection control efforts.
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