A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

Administering a potassium-sparing diuretic.

Administering sodium polystyrene sulfonate.

Initiating an IV potassium infusion.

Encouraging the client to eat bananas.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B) Administering sodium polystyrene sulfonate.

Choice A rationale:

Administering a potassium-sparing diuretic is not appropriate for a client with hyperkalemia (high potassium levels). Potassium-sparing diuretics would further increase potassium levels, worsening the condition.

Choice B rationale:

Sodium polystyrene sulfonate is used to treat hyperkalemia. It works by exchanging sodium ions for potassium ions in the intestines, which helps to lower serum potassium levels by excreting it through the stool.

Choice C rationale:

Initiating an IV potassium infusion would be contraindicated in this situation as it would increase the already elevated potassium levels, potentially leading to dangerous cardiac complications.

Choice D rationale:

Encouraging the client to eat bananas is not advisable because bananas are high in potassium, which would exacerbate hyperkalemia.

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Correct Answer is A

Explanation

Choice A rationale: Patients with bulimia are at increased risk for developing metabolic alkalosis due to recurrent vomiting, which leads to loss of hydrochloric acid from the stomach and results in an elevated blood bicarbonate level.

Choice B rationale: Patients with COPD are more likely to develop respiratory acidosis due to retention of carbon dioxide, not metabolic alkalosis.

Choice C rationale: Patients with venous stasis ulcers do not have a direct association with metabolic alkalosis.

Choice D rationale: Patients on dialysis are more likely to experience metabolic acidosis due to impaired kidney function and inability to excrete acid effectively.

A. Distended neck veins. B. Poor skin turgor. C. Concentrated hemoglobin and hematocrit levels. D. Decreased urine output.

Correct Answer is A

Explanation

Choice A rationale:

Fluid volume overload is an excess of fluid in the intravascular and/or interstitial spaces. One of the hallmark signs of fluid volume overload is distended neck veins, which indicates increased venous pressure due to the accumulation of fluid. The neck veins become more visible and prominent, especially when the patient is in a semi-Fowler's position.

Choice B rationale:

Poor skin turgor is a sign of dehydration, not fluid volume overload. It is characterized by the skin's inability to return to its normal position after being gently pinched. In fluid volume overload, the skin may become edematous and puffy, but it does not exhibit poor turgor.

Choice C rationale:

Concentrated hemoglobin and hematocrit levels are seen in conditions of dehydration or hemoconcentration, not in fluid volume overload. In fluid volume overload, there is excess fluid, which may lead to dilutional effects, resulting in decreased concentration of blood components.

Choice D rationale:

Decreased urine output is associated with fluid volume deficit (dehydration) rather than fluid volume overload. In fluid volume overload, there is often an increase in urine output as the body tries to eliminate the excess fluid.

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A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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