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
Cerebral ischemia due to an embolus that originates in the left atrium is a common complication of chronic atrial fibrillation (AFib). AFib causes irregular and chaotic electrical signals in the atria, leading to poor blood flow and the formation of blood clots. These clots can travel to the brain, causing a stroke. This is the most acute and severe event associated with chronic AFib.
Choice B rationale
Development of ventricular fibrillation is a life-threatening arrhythmia that can occur in patients with severe heart disease, but it is not a common acute event in chronic AFib.
Ventricular fibrillation involves the ventricles and is characterized by rapid, erratic electrical impulses, leading to ineffective heart contractions and sudden cardiac arrest.
Choice C rationale
Ischemia of the cerebellum due to a ruptured intracranial aneurysm is not directly related to chronic AFib. While AFib increases the risk of stroke, it does not specifically cause aneurysms or cerebellar ischemia. Aneurysms are typically related to other risk factors such as hypertension and vascular abnormalities.
Choice D rationale
Prolonged capillary refill secondary to a complete lack of cardiac output is a sign of severe cardiac dysfunction or shock. While AFib can lead to heart failure and reduced cardiac output, it does not typically cause a complete lack of cardiac output. The most acute event related to AFib is the formation of emboli and subsequent stroke.
Correct Answer is A
Explanation
Choice A rationale
Meningitis presents with fever, stiff neck, and photophobia. It is an inflammation of the membranes surrounding the brain and spinal cord, often caused by infection.
Choice B rationale
Encephalitis involves inflammation of the brain itself, presenting with fever, headache, and altered mental status, but not specifically photophobia.
Choice C rationale
Migraine can cause photophobia and headache but is not typically associated with fever and stiff neck.
Choice D rationale
Sinusitis can cause fever and headache but not typically photophobia and stiff neck.
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