A nurse is caring for a patient in acute renal failure who develops muscle weakness and an irregular heart rhythm. The provider prescribes an IV infusion of hypertonic glucose, regular insulin, and sodium bicarbonate. The nurse recognizes that these treatments are intended to manage which of the following complications?
Hypoglycemia
Hyperkalemia
Hypernatremia
Hypokalemia
The Correct Answer is B
Choice A reason: Hypoglycemia involves low blood glucose, causing symptoms like shakiness or confusion, not muscle weakness or arrhythmias. Hypertonic glucose and insulin would worsen hypoglycemia by increasing glucose uptake, and sodium bicarbonate is irrelevant. These symptoms and treatments align with hyperkalemia, not low glucose levels, in renal failure.
Choice B reason: Hyperkalemia, common in acute renal failure due to impaired potassium excretion, causes muscle weakness and cardiac arrhythmias by altering membrane potentials. Hypertonic glucose and insulin drive potassium into cells, while sodium bicarbonate corrects acidosis, stabilizing cardiac membranes, making this the targeted complication for the prescribed treatment.
Choice C reason: Hypernatremia (high sodium) causes neurological symptoms like confusion, not muscle weakness or arrhythmias. The prescribed treatments do not address sodium levels; insulin and glucose manage potassium, and bicarbonate corrects acidosis. Hypernatremia is not a primary concern in acute renal failure with these symptoms.
Choice D reason: Hypokalemia (low potassium) causes muscle weakness and arrhythmias but is rare in acute renal failure, where hyperkalemia is typical due to reduced excretion. The prescribed treatments aim to lower potassium, not increase it, making hypokalemia an incorrect target for this therapy in the context of renal failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: One-to-one observation for aggressive behavior is a standard safety measure to prevent harm, aligning with the right to safe care. It does not violate client rights when justified by clinical need, as it prioritizes protection without restricting autonomy unnecessarily, making it an appropriate intervention.
Choice B reason: Using physical restraints to prevent self-harm is permissible when less restrictive measures fail, aligning with the right to safety. If properly documented and justified, it does not violate rights, as mental health laws allow restraints for imminent danger, making this action compliant with client rights.
Choice C reason: Searching belongings at admission is standard in psychiatric settings to ensure safety (e.g., removing contraband). This practice, when conducted respectfully and per policy, does not violate client rights, as it prioritizes a safe therapeutic environment for all patients and staff on the unit.
Choice D reason: Lack of documentation of treatment benefits and options violates the right to informed consent. Clients must be informed about treatment rationale and alternatives to make autonomous decisions. Failure to document this breaches legal and ethical standards, undermining the client’s ability to participate in their care, making it a rights violation.
Correct Answer is ["50"]
Explanation
The correct answer is 50 drops per minute
Explanation:
Step 1 is identify the total volume to be infused
50 mL
Step 2 is identify the time in minutes
1 hour = 60 minutes
Step 3 is identify the drop factor for a microdrip set
Microdrip = 60 drops per mL
Step 4 is multiply the volume by the drop factor
50 × 60 = 3000 drops
Step 5 is divide total drops by time in minutes
(3000 ÷ 60) = 50
Result = 50 drops per minute
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