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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Obtaining the number of the client’s provider is not the immediate action to take. The client is showing signs of a possible stroke (right-sided weakness and slurred speech), which is a medical emergency.
Choice B rationale:
Finding a location for the client to sit is not the immediate action to take. The client needs medical attention immediately due to the signs of a possible stroke.
Choice C rationale:
Driving the client to the nearest emergency room is not the best action to take. It would be faster and safer to call emergency medical services who are trained to handle such situations.
Choice D rationale:
Calling emergency medical services is the correct action. The client is showing signs of a possible stroke, which requires immediate medical attention.
Correct Answer is A
Explanation
Choice A rationale:
Tachycardia, or a rapid heart rate, is a common early sign of hypovolemic shock as the body tries to compensate for the decreased blood volume by increasing the heart rate.
Choice B rationale:
Diminished urine output is a sign of hypovolemic shock, but it is not typically an early sign.
Choice C rationale:
Cold, clammy skin is a sign of hypovolemic shock, but it is not typically an early sign.
Choice D rationale:
Unconsciousness is a late sign of hypovolemic shock, indicating severe blood loss and inadequate perfusion to the brain.
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