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:
Low blood pressure (BP) is a symptom of hypovolemic shock due to decreased blood volume, but the pulse rate typically increases as the body tries to compensate for the low BP, not decrease.
Choice B rationale:
Hypovolemic shock is characterized by low BP due to loss of blood or fluid volume and a high pulse rate as the body tries to compensate for the decreased blood flow.
Choice C rationale:
High BP is not typically associated with hypovolemic shock. Instead, BP is usually low due to decreased blood volume.
Choice D rationale:
High BP is not typically a symptom of hypovolemic shock. While the pulse rate may be high as the body tries to compensate for low blood volume, the BP is usually low.
Correct Answer is B
Explanation
Choice A rationale:
Urine specific gravity 1.020 is within the normal range (1.005-1.030), so it does not indicate fluid volume deficit.
Choice B rationale:
Urine output 15 mL/hr is less than the normal minimum of 30 mL/hr, indicating fluid volume deficit.
Choice C rationale:
Hct 43% is within the normal range (38.8-50.0 for men, 34.9-44.5 for women), so it does not indicate fluid volume deficit.
Choice D rationale:
BUN 12 mg/dL is within the normal range (7-20 mg/dL), so it does not indicate fluid volume deficit.
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