A nurse is caring for a client with chronic kidney disease (CKD) who presents with hyperkalemia. Which of the following interventions should the nurse implement first?
Administer sodium polystyrene sulfonate as prescribed.
Monitor the client’s cardiac rhythm.
Restrict dietary potassium intake.
Prepare the client for hemodialysis.
The Correct Answer is B
Choice A rationale
Administering sodium polystyrene sulfonate helps to lower potassium levels by exchanging sodium ions for potassium ions in the intestines. However, it is not the first intervention because it takes time to work and does not address the immediate risk of cardiac arrhythmias caused by hyperkalemia.
Choice B rationale
Monitoring the client’s cardiac rhythm is the first intervention because hyperkalemia can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these arrhythmias, which is crucial for the client’s safety.
Choice C rationale
Restricting dietary potassium intake is an important long-term management strategy for hyperkalemia, especially in clients with chronic kidney disease. However, it does not address the immediate risk of cardiac arrhythmias and is not the first intervention.
Choice D rationale
Preparing the client for hemodialysis is a definitive treatment for hyperkalemia, especially in clients with chronic kidney disease. However, it is not the first intervention because it takes time to arrange and initiate dialysis. Immediate cardiac monitoring is necessary to manage the acute risk of arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Septic shock is a severe infection leading to systemic inflammation, characterized by high fever (39°C), low blood pressure (90/60 mmHg), and signs of organ dysfunction. It is a medical emergency requiring immediate intervention.
Choice B rationale
Cardiogenic shock is caused by the heart’s inability to pump blood effectively, leading to hypotension and signs of poor perfusion, but not necessarily high fever.
Choice C rationale
Neurogenic shock results from a disruption in the autonomic pathways, leading to hypotension and bradycardia, but not high fever.
Choice D rationale
Anaphylactic shock is a severe allergic reaction causing hypotension, respiratory distress, and other symptoms, but not typically high fever.
Correct Answer is C
Explanation
Choice A rationale
Wearing an N95 mask is appropriate for airborne precautions, such as tuberculosis, but not specifically for MRSA, which requires contact precautions.
Choice B rationale
Wearing a facemask is suitable for droplet precautions, such as influenza, but MRSA is primarily spread through direct contact, not droplets.
Choice C rationale
Using a separate disposable blood pressure cuff for patients with draining wounds helps prevent the spread of MRSA. MRSA can be transmitted via contaminated medical equipment.
Choice D rationale
Strict hand washing measures are essential but should be performed more frequently than once every 8-hour shift. Hand hygiene should be practiced before and after patient contact.
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