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.
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Related Questions
Correct Answer is C
Explanation
A. Laryngospasm: Laryngospasm is not a commonly associated adverse effect of alteplase administration. It is more commonly associated with airway irritants or allergic reactions.
B. Polycythemia: Polycythemia, or an abnormally high red blood cell count, is not a typical adverse effect of alteplase administration. Alteplase is a thrombolytic agent used to dissolve blood clots and is not associated with increasing red blood cell production.
C. Hemorrhage: Hemorrhage, or bleeding, is the most significant adverse effect associated with alteplase administration. Alteplase works by promoting fibrinolysis and can increase the risk of bleeding, including intracranial hemorrhage, particularly in the context of thrombolytic therapy for stroke.
D. Steatorrhea: Steatorrhea, or fatty stools, is not a commonly associated adverse effect of alteplase administration. It is more commonly associated with malabsorption disorders or pancreatic insufficiency.
Correct Answer is B
Explanation
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.
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