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 B
Explanation
A. 0.45% sodium chloride: 0.45% sodium chloride solution, also known as half-normal saline, is a hypotonic solution used for rehydration and maintenance fluid therapy. However, in cases of
major burns where there is a significant loss of fluid and electrolytes, isotonic solutions are generally preferred.
B. Lactated Ringer's: Lactated Ringer's solution is an isotonic crystalloid solution that closely resembles the electrolyte composition of extracellular fluid. It is commonly used for fluid resuscitation in clients with major burns to replace lost fluids and electrolytes and restore
intravascular volume.
C. Dextrose 5% in water: Dextrose 5% in water is a hypotonic solution used primarily for hydration in clients with normal electrolyte levels or as a vehicle for administering medications.
It is not typically used for fluid resuscitation in clients with major burns, as it does not adequately replace lost electrolytes.
D. Dextrose 5% in 0.45% sodium chloride: This solution combines dextrose 5% and 0.45% sodium chloride and is used for maintenance fluid therapy and mild dehydration. However, in cases of major burns where there is significant fluid and electrolyte loss, isotonic solutions like lactated Ringer's or normal saline are preferred for fluid resuscitation.
Correct Answer is ["1.5"]
Explanation
Convert the client's weight from pounds to kilograms by dividing by 2.2. 198 lb / 2.2 = 90 kg
Calculate the dose of filgrastim in micrograms by multiplying the client's weight in kilograms by the prescribed dose per kilogram. 90 kg x 5 mcg/kg = 450 mcg
Calculate the volume of filgrastim in milliliters by dividing the dose in micrograms by the concentration of the available solution. 450 mcg / 300 mcg/mL = 1.5 mL
Round the answer to the nearest tenth. The nurse should plan to give 1.5 mL of filgrastim with each dose.
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