A nurse is caring for a client who is receiving parenteral nutrition and identifies that the client has hyperkalemia. Which of the following actions should the nurse take?
Warm formula to room temperature.
Place the client on a cardiac monitor.
Administer IV dextrose.
Request a lactose-free formula.
The Correct Answer is B
A. Warming the formula to room temperature would not address hyperkalemia.
B. Hyperkalemia can lead to cardiac dysrhythmias, so placing the client on a cardiac monitor
allows for continuous cardiac monitoring to detect any changes or abnormalities in heart rhythm.
C. Administering IV dextrose is not typically indicated for hyperkalemia. Instead, insulin may be administered with dextrose to promote cellular uptake of potassium.
D. Requesting a lactose-free formula is not relevant to the management of hyperkalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. “I can cut the patches in half to save money": Cutting nitroglycerin patches is not recommended as it can alter the medication's release rate and efficacy. Therefore, this statement indicates a misunderstanding and should be corrected.
B. “I will apply a new patch to the same site whenever I replace it": Rotating patch sites is essential to prevent skin irritation and tolerance development. Therefore, this statement indicates a misunderstanding and should be corrected.
C. “I will take the patch off after dinner every night": This statement demonstrates understanding because nitroglycerin patches are typically worn for a certain number of hours (e.g., 12-14 hours) and then removed for a drug-free interval to prevent tolerance development.
D. "I can put a second patch on if I have chest pain": Applying multiple nitroglycerin patches simultaneously can lead to excessive vasodilation and hypotension, which can be dangerous. Therefore, this statement indicates a misunderstanding and should be corrected.
Correct Answer is D
Explanation
A. Pallor: Pallor refers to paleness of the skin and is not typically associated with an allergic reaction to penicillin G IM.
B. Dyspepsia: Dyspepsia refers to indigestion or discomfort in the upper abdomen and is not typically associated with an allergic reaction to penicillin G IM.
C. Bradycardia: Bradycardia refers to a slow heart rate and is not typically associated with an allergic reaction to penicillin G IM.
D. Urticaria: Urticaria, commonly known as hives, is a characteristic manifestation of an allergic reaction to penicillin G IM. It presents as raised, red, itchy welts on the skin.
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