Which client will the nurse observe frequently for indications of hyperkalemia?

Client receiving total parenteral nutrition

Client taking furosemide for chronic heart failure

Client admitted for diabetic ketoacidosis

Client with anxiety-induced hyperventilation

Answer and Explanation

The Correct Answer is C

A. Client receiving total parenteral nutrition (TPN): TPN is typically formulated with electrolytes, including potassium, but it does not inherently increase the risk of hyperkalemia unless there is an issue with kidney function or an excessive amount of potassium in the formula.

B. Client taking furosemide for chronic heart failure: Furosemide is a loop diuretic that causes the body to excrete potassium through urine, which actually puts the client at risk for hypokalemia, not hyperkalemia.

C. Client admitted for diabetic ketoacidosis (DKA): In DKA, the body produces excess acidic ketones, leading to metabolic acidosis. As a compensatory mechanism, potassium is shifted from the inside of cells into the bloodstream, leading to hyperkalemia, despite actual total body potassium depletion.

D. Client with anxiety-induced hyperventilation: Hyperventilation typically leads to respiratory alkalosis, which may cause a shift in potassium levels but does not directly cause hyperkalemia. Anxiety-induced hyperventilation is less likely to result in hyperkalemia compared to DKA.

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Correct Answer is D

Explanation

A. Decreased CO2: Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2), not a decrease. Decreased CO2 would lead to respiratory alkalosis, not acidosis.

B. Overproduction of hydrogen ions: While the overproduction of hydrogen ions can lead to acidosis, this is typically seen in metabolic acidosis, not respiratory acidosis. In respiratory acidosis, the issue is related to CO2 retention, not hydrogen ion production.

C. Hyperventilation: Hyperventilation leads to the exhalation of excessive CO2, which would decrease CO2 levels in the blood. This results in respiratory alkalosis, not acidosis.

D. Retention of CO2: Respiratory acidosis occurs when the lungs are unable to exhale enough CO2, leading to its retention in the blood. This increased CO2 concentration causes a decrease in pH, resulting in respiratory acidosis.

A. Avoid hanging the IV with K and inform the registered nurse (RN) of the urine output. B. Run the IV rapidly for 30 minutes to stimulate urine production. C. Call the physician who ordered the K+. D. Hang the IV as ordered and chart the output.

Correct Answer is A

Explanation

A. Avoid hanging the IV with K and inform the registered nurse (RN) of the urine output: The low urine output suggests potential renal impairment, which could lead to potassium retention. Administering potassium could cause dangerous hyperkalemia, so it’s important to hold the IV and consult the RN for further evaluation.

B. Run the IV rapidly for 30 minutes to stimulate urine production: Rapid infusion could worsen fluid overload or cause other complications, and it will not address the renal issue causing the low urine output. Potassium should be avoided to prevent complications.

C. Call the physician who ordered the K+: While notifying the physician is important, the immediate priority is to inform the RN, as the potassium infusion should be withheld until renal function is assessed and corrected, if necessary.

D. Hang the IV as ordered and chart the output: Hanging the IV with potassium is risky in this case, as the client may not be able to eliminate potassium due to decreased renal function. Monitoring urine output is crucial before proceeding with potassium administration.

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Which client will the nurse observe frequently for indications of hyperkalemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What causes respiratory acidosis?

Correct Answer is D

Explanation

A licensed practical/vocational nurse (LPN/LVN) is preparing to add a new IV of 5% dextrose in water (D5W) with potassium (K) to an existing line. The LPN/LVN notices that only 25 mL of urine has been collected over the past hour. What is the most appropriate nursing intervention?

Correct Answer is A

Explanation

A client at risk for developing hyperkalemia states, "I love fruit and usually eat it every day, but now I can't because of my high potassium level." How should the nurse respond?

The nurse is aware that the compensating mechanism that is most likely to occur in the presence of respiratory acidosis is:

When administering potassium chloride, which of following safety precautions must be observed? (Select all that apply)

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