A nurse is reviewing laboratory values of a client with chronic renal failure and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?
Administering sodium polystyrene sulfonate.
Initiating an IV potassium infusion.
Administering a potassium-sparing diuretic.
Encouraging the client to eat bananas.
The Correct Answer is A
A. Administering sodium polystyrene sulfonate:
This medication removes potassium through the GI tract and is used to treat hyperkalemia.
B. Initiating an IV potassium infusion:
The client already has hyperkalemia; giving potassium would worsen it.
C. Administering a potassium-sparing diuretic:
These medications retain potassium and would further elevate potassium levels.
D. Encouraging the client to eat bananas:
Bananas are high in potassium and should be avoided in hyperkalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encourage the client to cough and auscultate the lungs again:
This delays necessary intervention and is not appropriate for suspected airway compromise.
B. Document the change and continue to monitor the client's respiratory rate:
Passive monitoring is not safe here given signs of impending respiratory failure.
C. Notify the health care provider and prepare for endotracheal intubation:
Facial burns and decreasing breath sounds suggest airway edema—immediate intubation is critical before complete airway obstruction.
D. Reposition the client in high-Fowler's position and reassess breath sounds:
While positioning helps breathing, it’s not sufficient or timely enough in a rapidly deteriorating airway.
Correct Answer is ["A","D","E"]
Explanation
A. Blistering of area: Blisters are characteristic of superficial partial-thickness burns, involving the epidermis and part of the dermis.
B. Dry crusting surface: This is more typical of deeper burns; partial-thickness burns are moist.
C. Intact skin surface: The skin is not intact; it is damaged and blistered.
D. Blanching of wound area: Indicates intact capillary refill and superficial depth.
E. Pain at wound site: Nerve endings are exposed, making these burns very painful.
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