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 B
Explanation
Choice A rationale:
Checking for a positive Chvostek’s sign is not relevant. This sign is associated with hypocalcemia, not with the lab values provided.
Choice B rationale:
The nurse should request a potassium replacement. The normal range for potassium is 3.5-5.0 mEq/L. A level of 3.0 mEq/L is low, indicating hypokalemia.
Choice C rationale:
Administering glucagon IM is not appropriate. The glucose level is within the normal range (70-110 mg/dL), so there is no need for glucagon.
Choice D rationale:
Discontinuing the TPN infusion is not the first action. The nurse should address the abnormal lab value (low potassium) first.
Correct Answer is D
Explanation
Choice A rationale:
Decreased deep-tendon reflexes are not a common symptom of hypocalcemia. Normal calcium levels in the blood range from 8.5 to 10.2 mg/dL1.
Choice B rationale:
Skeletal muscle weakness is a symptom of hypercalcemia, not hypocalcemia.
Choice C rationale:
Hypoactive bowel sounds are associated with hypercalcemia, not hypocalcemia.
Choice D rationale:
Tingling of the lips is a common symptom of hypocalcemia. This occurs due to increased excitability of the nerves.
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