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 B
Explanation
Choice A reason: The erythrocyte sedimentation rate (ESR) is not directly affected by epoetin alfa therapy, which is used to treat anemia.
Choice B reason: Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production, which would be reflected in an increased hematocrit level.
Choice C reason: The platelet count is not directly affected by epoetin alfa therapy.
Choice D reason: The leukocyte count is not directly affected by epoetin alfa therapy.
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: Headache and restlessness can be signs of a seizure or neurological disturbance, which phenytoin is used to treat. Phenytoin is an anticonvulsant medication that helps control seizures by stabilizing neuronal membranes and reducing excitability.
Choice B rationale: Decreased blood pressure and rapid pulse are not indications for phenytoin administration. These symptoms may suggest hypotension or cardiovascular issues, which require different interventions such as fluid resuscitation or vasopressors.
Choice C rationale: Muscle cramps and chest heaviness are not treated with phenytoin. These symptoms could indicate electrolyte imbalances or cardiac issues, which need specific treatments like electrolyte replacement or cardiac monitoring.
Choice D rationale: Pain and tingling at the access site are not indications for phenytoin administration. These symptoms may suggest local irritation or infection at the dialysis access site, requiring appropriate wound care or antibiotics.
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