A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?
Repeat the potassium level.
Withhold the medication.
Monitor for paresthesia.
Administer a hypertonic solution.
The Correct Answer is B
Choice A rationale:
Repeating the potassium level is not the first action to take. The nurse already has a recent lab value.
Choice B rationale:
The nurse should withhold the medication. The normal range for potassium is 3.5-5.0 mEq/L. A level of 5.5 mEq/L is high, so giving more potassium could lead to hyperkalemia.
Choice C rationale:
Monitoring for paresthesia is important in hyperkalemia, but it is not the first action. The nurse should first prevent further increase in potassium levels.
Choice D rationale:
Administering a hypertonic solution is not relevant in this situation. It does not directly address the high potassium level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Respiratory acidosis is characterized by a high PaCO2 and a low pH. The client’s ABG results do not match this pattern.
Choice B rationale:
Metabolic acidosis is characterized by a low HCO3 and a low pH. The client’s ABG results do not match this pattern.
Choice C rationale:
Respiratory alkalosis is characterized by a low PaCO2 and a high pH. The client’s ABG results do not match this pattern.
Choice D rationale:
Metabolic alkalosis is characterized by a high HCO3 and a high pH. The client’s ABG results match this pattern. Normal values for pH, PaCO2, and HCO3 are 7.35-7.45, 35-45 mm Hg, and 22-26 mEq/L respectively.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
A blood pressure of 108/60 mm Hg is considered normal, as it is less than 120/80 mm Hg.
Choice B rationale:
A blood pressure of 154/96 mm Hg falls into the category of stage 1 hypertension. Stage 1 hypertension is classified as a systolic blood pressure reading that falls between 130 and 139 mm Hg or a diastolic reading that is between 80 and 89 mm Hg.
Choice C rationale:
A blood pressure of 164/104 mm Hg is considered stage 2 hypertension, as the systolic blood pressure is 140 mm Hg or higher, or the diastolic pressure is 90 mm Hg or higher.
Choice D rationale:
A blood pressure of 128/88 mm Hg is considered elevated, as the systolic blood pressure ranges from 120 to 129 mm Hg and the diastolic blood pressure is below 80 mm Hg.
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