A nurse is preparing to administer oral potassium to a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?

Withhold the medication.

Administer a hypertonic solution.

Repeat the potassium level.

Monitor for paresthesia.

Answer and Explanation

The Correct Answer is C

Before administering any medication, the nurse should confirm the potassium level to ensure that it is still elevated and needs to be treated. Potassium levels can ﬂuctuate, so repeating the test will ensure that the client receives the appropriate treatment.

Options (a) Withhold the medication and (b) Administering a hypertonic solution may be appropriate interventions depending on the client's condition, but confirming the potassium level is the first step.

Option (d) Monitoring for paresthesia is important but not the first action that the nurse should take.

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Correct Answer is D

Explanation

One of the hallmarks of adrenal insufficiency is dehydration and decreased urinary output, which can lead to electrolyte imbalances such as hyperkalemia and hyponatremia. As treatment begins to take eﬀect, the patient's ﬂuid and electrolyte balance should improve, leading to an increase in urinary output. Acute adrenal insufficiency, also known as the Addisonian crisis, is a life-threatening condition caused by a sudden decrease in cortisol and aldosterone hormones. Treatment usually involves the administration of intravenous glucocorticoids and mineralocorticoids to replace the deficient hormones.
Decreasing serum sodium (a) and decreasing blood glucose (b) are not signs of improvement but rather indicative of continued adrenal insufficiency. Decreasing serum potassium (c) is also not a sign of improvement as it could indicate that the patient is developing hyperkalemia, which is a potential complication of adrenal crisis.

A. institute seizure precautions such as padded side rails. B. assist the patient to perform range-of-motion exercises QID. C. encourage the patient to drink 4000 ml of ﬂuid daily. D. monitor the patient for positive Chvostek’s or Trousseaus sign.

Correct Answer is C

Explanation

The patient with primary hyperparathyroidism has high levels of calcium in the blood (hypercalcemia) which can lead to symptoms such as kidney stones, bone pain, and weakness. High urine calcium levels may also be present due to the increased calcium in the blood.

One important intervention for managing hypercalcemia is to encourage ﬂuid intake to promote increased urine output and prevent the formation of kidney stones. Therefore, the nurse should encourage the patient to drink at least 4000 ml of ﬂuids per day.

Seizure precautions (a), range-of-motion exercises (b), and monitoring for positive Chvostek’s or Trousseaus sign (d) are not directly related to managing hypercalcemia and are not necessary in this case.

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A nurse is preparing to administer oral potassium to a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is hospitalized with acute adrenal insufficiency. The nurse determines that the patient is responding favorably to treatment on finding:

Correct Answer is D

Explanation

A patient with primary hyperparathyroidism has a serum calcium level of 14 mg/dl (3.5 mmol/L), phosphorus of 1.7 mg/dl (55 mmol/L), serum creatinine of 2.2 mg/dl (194 mmol/L). and high urine calcium. While the patient awaits surgery, the nurse should:

Correct Answer is C

Explanation

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