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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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

The thickest part of the heart is not the upper chambers but the lower chambers, specifically the left ventricle. This is because it needs to pump blood to the entire body.

Choice B rationale:

Blood leaves the heart through the lower chambers, or ventricles, not the upper chambers.

Choice C rationale:

Blood enters the heart through the upper chambers, or atria. This is where deoxygenated blood from the body and oxygenated blood from the lungs first enter the heart.

Choice D rationale:

The term “ventricles” refers to the lower chambers of the heart, not the upper chambers.

A. Drop prescribed amount of medication into the conjunctival sac. B. Place the eyedropper gently against the sclera. C. Don sterile gloves to instill the medication. D. Gently rub the eye after instilling the medication.

Correct Answer is A

Explanation

Choice A rationale:

The medication should be dropped into the conjunctival sac, which is the space between the lower eyelid and the eyeball. This is the correct method for administering ophthalmic drops.

Choice B rationale:

The eyedropper should not touch any part of the eye, including the sclera, to avoid contamination and potential infection.

Choice C rationale:

It is not necessary to don sterile gloves when administering ophthalmic drops. Clean gloves or hand hygiene is sufficient.

Choice D rationale:

Rubbing the eye after instilling medication can cause irritation and may disperse the medication, reducing its effectiveness.

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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?

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Naxlex Comprehensive Predictor Exams

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