Your labs are potassium 6.4, sodium 138, and serum calcium level of 9. Which order from the healthcare provider would the nurse anticipate?
Fluid restriction
Neomycin
Kayexalate
Sodium chloride infusion and furosemide
The Correct Answer is C
Choice A reason: Fluid restriction doesn’t address hyperkalemia (6.4 mEq/L); it may concentrate potassium further, worsening the condition, as it’s unrelated to potassium excretion or shifting in this scenario.
Choice B reason: Neomycin, an antibiotic, reduces gut bacteria but isn’t used for hyperkalemia. It has no direct effect on potassium levels, making it irrelevant for this lab finding.
Choice C reason: Kayexalate binds potassium in the gut, facilitating its fecal excretion, effectively lowering serum levels (6.4 mEq/L) in hyperkalemia, aligning with urgent correction needs here.
Choice D reason: Sodium chloride and furosemide dilute and excrete potassium via urine, but Kayexalate is preferred for rapid gut-based removal when potassium is critically high (6.4 mEq/L).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Captopril, an ACE inhibitor, lowers blood pressure, risking orthostatic hypotension; teaching posture changes (slow standing) prevents falls, a key safety instruction.
Choice B reason: Captopril is taken on an empty stomach for optimal absorption, as food reduces bioavailability, so this statement contradicts proper administration guidelines.
Choice C reason: Cough, an ACE inhibitor side effect, doesn’t warrant suppressants; it may require switching drugs, not masking, making this instruction inappropriate.
Choice D reason: Captopril can raise potassium by reducing aldosterone; high-potassium foods risk hyperkalemia, so this advice is unsafe without monitoring levels.
Correct Answer is D
Explanation
Choice A reason: Increasing oxygen to 3 L/min may help but risks CO2 retention in COPD without assessing respiratory rate, depth, and saturation first, making it premature.
Choice B reason: Coughing clears secretions, but without assessing respiratory status, it’s unclear if secretions are the issue or if the client can effectively cough, so it’s not priority.
Choice C reason: Calling emergency services assumes severity without data like oxygen saturation or distress level, delaying care by skipping initial assessment in this stable setting.
Choice D reason: Assessing respiratory status (rate, oxygen saturation, lung sounds) identifies the cause of difficulty, guiding interventions like oxygen adjustment or escalation, per ABC priority.
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