A nurse is preparing to administer prescribed intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L (normal range: 3.5 to 5 mEq/L). Which of the following actions should the nurse plan to include? (Select all that apply.)
Ensure that the client's urine output is at least 1 mL/kg/hour.
Educate the client regarding high-potassium food sources.
Cardiac monitoring during infusion.
Repeat blood serum potassium.
Ensure potassium infusion is prepared with 5% dextrose solution.
Correct Answer : A,C,D
Choice A reason: Ensuring the client's urine output is at least 1 mL/kg/hour is important before administering potassium to prevent hyperkalemia, especially in clients with renal impairment.
Choice B reason: While educating the client about high-potassium food sources is important, it is not directly related to the administration of intravenous potassium.
Choice C reason: Cardiac monitoring during infusion is crucial due to the risk of arrhythmias associated with rapid
changes in potassium levels.
Choice D reason: Repeating blood serum potassium is necessary to monitor the effectiveness of the supplementation and avoid hyperkalemia.
Choice E reason: Potassium should not be prepared with 5% dextrose solution as it may cause a trans-cellular shift of potassium into cells, which is not recommended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Maintaining the client in a left lateral position is not specifically required for peritoneal dialysis. Positioning may vary based on the individual's comfort and specific medical needs.
Choice B reason: While monitoring vital signs is important during any medical procedure, it is not an intervention that directly ensures proper dialysate exchange in peritoneal dialysis.
Choice C reason: Warming the dialysate solution prior to instillation is a standard practice in peritoneal dialysis. It helps to promote patient comfort and more efficient exchange of wastes and fluids.
Choice D reason: Placing the drainage bag above the level of the client's abdomen would impede gravity drainage, which is necessary for proper dialysate exchange. The drainage bag should be placed below the level of the client's abdomen.
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Correct Answer is A
Explanation
Choice A reason: General anesthesia can impair the autonomic nervous system, which controls bladder function, leading to urinary retention. This risk is particularly high shortly after surgery.
Choice B reason: While liver failure can lead to multiple organ dysfunction, it is not directly associated with urinary retention unless there are concurrent issues affecting the urinary system.
Choice C reason: A diet high in calcium oxalate can contribute to kidney stones, which could potentially cause urinary obstruction, but it is not a direct cause of urinary retention.
Choice D reason: Antibiotics for a skin infection would not typically lead to urinary retention unless there were an allergic reaction or other rare side effects that affect the urinary system.
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