A nurse cares for a patient who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which should the nurse implement first?

Provide a heart healthy low potassium diet

Prepare to administer sodium polystyrene sulfate 15g by mouth

Prepare the patient for hemodialysis treatment

Prepare to administer dextrose 20% and 10 units of regular insulin IV push

Answer and Explanation

The Correct Answer is D

A. Provide a heart-healthy low-potassium diet:

While a heart-healthy low-potassium diet is essential for managing chronic hyperkalemia and preventing future occurrences, it is not the first intervention to implement in a patient with a serum potassium level of 7.5 mEq/L and exhibiting cardiovascular changes. The effects of dietary changes on serum potassium levels are gradual and may take days to have a significant impact. In an acute situation like this, immediate interventions are needed to rapidly lower potassium levels and address the associated cardiovascular risks.

B. Prepare to administer sodium polystyrene sulfate 15g by mouth:

Sodium polystyrene sulfate is a medication used to exchange sodium for potassium in the gastrointestinal tract, effectively lowering serum potassium levels over hours to days. While it is a valid treatment for hyperkalemia, its onset of action is not immediate enough to address the urgent cardiovascular changes seen in severe hyperkalemia. Therefore, it is not the first-line intervention in this scenario.

C. Prepare the patient for hemodialysis treatment:

Hemodialysis is an effective method for rapidly lowering serum potassium levels in cases of severe hyperkalemia. However, it is a more invasive and time-consuming procedure that requires preparation, including vascular access and dialysis setup. It is typically reserved for situations where other interventions have failed or in patients with severe or refractory hyperkalemia. In the context of this scenario, where the patient has a serum potassium level of 7.5 mEq/L and is exhibiting cardiovascular changes, hemodialysis may be considered if initial interventions are not successful, but it is not the first action to implement.

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Correct Answer is C

Explanation

A. Increase the effectiveness of the skin graft:

Debridement can indeed increase the effectiveness of a skin graft by preparing a clean, viable wound bed for grafting. Removing dead tissue and debris helps the skin graft adhere to healthy tissue and promotes successful graft take. However, this is not the primary purpose of debridement.

B. Promote movement in the affected area:

While debridement can indirectly contribute to promoting movement by improving wound healing and reducing pain, the primary purpose of debridement is not to promote movement in the affected area.

C. Prevent infection and promote healing:

This statement accurately reflects the primary purpose of debridement. By removing nonviable tissue, debris, and foreign material from the wound, debridement helps prevent infection by reducing the bacterial load and creating an environment conducive to healing. It also promotes granulation tissue formation and wound contraction, which are essential for wound healing.

D. Promote suppuration of the wound:

Suppuration refers to the formation and discharge of pus from a wound, often indicating infection. Debridement aims to remove necrotic tissue and prevent infection, so promoting suppuration is not a desired outcome of debridement.

A. There is no redness, warmth, or drainage at the insertion site. B. Drainage from the surgical site is 30 mL less than yesterday. C. The patient reports adequate pain control with medications. D. Urine is clear yellow and urine output is greater than 40 mL/hr

Correct Answer is A

Explanation

A. There is no redness, warmth, or drainage at the insertion site.

This assessment is crucial for evaluating the status of the abdominal drain site. The absence of redness, warmth, or drainage suggests that the insertion site is healing well without signs of infection or inflammation. It indicates that the drain is functioning properly and that there are no immediate complications related to the drain insertion. This assessment directly addresses the goals related to monitoring the drain site for signs of infection or dysfunction.

B. Drainage from the surgical site is 30 mL less than yesterday.

Monitoring the drainage output from the surgical site is important to assess for changes in drainage patterns. A decrease in drainage volume may indicate reduced fluid accumulation at the surgical site, potentially reflecting improved healing and decreased need for drainage. However, while this assessment is valuable, it is not as directly related to assessing the status of the drain itself or evaluating complications at the insertion site as option A.

C. The patient reports adequate pain control with medications.

Pain control is an essential aspect of postoperative care, but it is not specifically related to assessing the functionality or complications of the abdominal drain. While pain management is important for patient comfort and recovery, it does not directly address the goals related to monitoring the drain site for signs of infection, leakage, or other complications.

D. Urine is clear yellow, and urine output is greater than 40 mL/hr.

While monitoring urine output and characteristics is important for assessing renal function and hydration status, it is not directly related to assessing the abdominal drain or its complications. Clear yellow urine and adequate urine output are generally positive indicators but do not provide specific information about the functionality or status of the drain.

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A nurse cares for a patient who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which should the nurse implement first?

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