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 : B,C,D
Choice A rationale: Potassium is primarily excreted by the kidneys. While adequate renal function is necessary, the standard minimum urine output for adults is 30 mL/hour rather than 1 mL/kg/hour.
Choice B rationale: Low potassium levels (2.5 mEq/L) require long-term management. Educating the client on potassium-rich foods like bananas and potatoes helps prevent future depletion and supports overall electrolyte balance.
Choice C rationale: Severe hypokalemia and rapid IV replacement increase the risk of lethal cardiac dysrhythmias. Continuous ECG monitoring is vital to detect life-threatening changes in cardiac conduction and rhythm.
Choice D rationale: Following intravenous replacement, serum levels must be re-evaluated to confirm the effectiveness of the treatment and ensure the client does not develop iatrogenic hyperkalemia.
Choice E rationale: Dextrose stimulates insulin secretion, which causes an intracellular shift of potassium. This can lead to a further decrease in serum potassium levels, worsening the client's hypokalemia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While a heart atack is a serious condition, it is not directly related to peritonitis. Peritonitis can lead to systemic infection, which may indirectly affect the heart, but it is not the primary concern in the immediate care of peritonitis.
Choice B reason: Diabetes is a chronic condition that requires ongoing management. However, it is not the most immediate threat when a client is diagnosed with peritonitis. The nurse should continue to monitor blood glucose levels as part of routine care.
Choice C reason: Respiratory failure can be a complication of peritonitis if the infection spreads and affects other systems. However, the primary concern with peritonitis is the potential for the infection to lead to sepsis.
Choice D reason: Sepsis is a life-threatening condition that can occur as a complication of peritonitis. It happens when the body's response to infection causes injury to its own tissues and organs. Monitoring for signs of sepsis is crucial because early intervention can be lifesaving.
Correct Answer is B
Explanation
Choice A reason: Diagnosis is the identification of a disease or condition, which is not directly related to reviewing kidney function test data.
Choice B reason: Assessment involves collecting and analyzing data, which is what the nurse is doing when reviewing kidney function test results.
Choice C reason: Implementation refers to carrying out interventions, not reviewing test data.
Choice D reason: Outcomes identification involves setting goals and expected outcomes, not reviewing test data.
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