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. Urinary retention: While urinary retention can be a complication of epidural anesthesia, it is not the priority finding in this scenario. The priority is to address potential complications that can lead to maternal or fetal compromise.
B. Leg weakness: Leg weakness can occur as a side effect of epidural anesthesia but is not the priority finding in this scenario unless it is severe and compromises the client's ability to
mobilize or push during labor.
C. Hypotension: Hypotension is a common complication of epidural anesthesia due to sympathetic blockade, which can lead to decreased venous return and subsequent maternal
hypotension. Maternal hypotension can compromise uteroplacental perfusion, leading to fetal distress. Therefore, addressing hypotension promptly is the priority to prevent adverse maternal and fetal outcomes.
D. Temperature 39°C (102.2°F): While fever should be monitored and addressed, it is not the priority finding in this scenario unless it indicates an infection, which would require further assessment and intervention. However, maternal hypotension poses a more immediate risk to both the mother and the fetus during labor.
Correct Answer is D
Explanation
A. The client's liver function test results are within the expected reference range: While monitoring liver function tests is essential for clients taking isoniazid and rifampin due to
potential hepatotoxicity, normal liver function test results do not necessarily indicate adherence to the medication regimen. Adherence is best assessed by the client's response to treatment, such as improvement in symptoms and resolution of the infection.
B. The client has a positive purified protein derivative test: A positive purified protein derivative (PPD) test indicates exposure to Mycobacterium tuberculosis but does not provide information about the client's adherence to the medication regimen for tuberculosis treatment. Adherence to treatment is determined by factors such as medication compliance and therapeutic response.
C. The client tests negative for HIV: The client's HIV status is not directly related to adherence to the tuberculosis medication regimen. While co-infection with HIV can impact the management of tuberculosis, testing negative for HIV does not confirm adherence to tuberculosis treatment.
D. The client has a negative sputum culture: A negative sputum culture indicates the absence of viable Mycobacterium tuberculosis organisms in the sputum sample and suggests effective
treatment and adherence to the medication regimen. Monitoring sputum culture conversion is a key indicator of treatment success in tuberculosis therapy.
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