A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?
Have the laboratory draw a blood sample for an erythrocyte sedimentation rate
Obtain a 12-lead ECG
Administer potassium gluconate 40 mEq orally
Restrict fluid intake
The Correct Answer is B
Choice A reason : An erythrocyte sedimentation rate (ESR) test is not directly related to high serum potassium levels and would not be the immediate action in response to hyperkalemia.
Choice B reason : Obtaining a 12-lead ECG is a critical step when hyperkalemia is suspected because high potassium levels can cause life-threatening cardiac arrhythmias. An ECG can quickly reveal characteristic changes associated with hyperkalemia, allowing for prompt treatment.
Choice C reason : Administering potassium gluconate would be contraindicated in a patient with hyperkalemia, as it would further increase the serum potassium levels, potentially leading to severe complications.
Choice D reason : Restricting fluid intake is not a standard treatment for hyperkalemia. The management of hyperkalemia may include medications or procedures that promote the excretion of potassium or move potassium from the blood into the cells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason : The triglyceride level of 130 mg/dL is within the normal range, which is less than 150 mg/dL for adults. Therefore, this result does not place the client at risk for peripheral arterial disease.
Choice B reason : An HDL level of 84 mg/dL is considered good as it is higher than the minimum recommended level of 40 mg/dL for males and 50 mg/dL for females. Higher levels of HDL are protective against heart disease.
Choice C reason : A blood glucose level of 92 mg/dL is within the normal fasting range of 70 to 99 mg/dL. This indicates that the client does not have diabetes, which is a risk factor for peripheral arterial disease.
Choice D reason : An LDL level of 172 mg/dL is considered high since the optimal level for LDL is less than 100 mg/dL. High levels of LDL cholesterol can lead to atherosclerosis, increasing the risk for peripheral arterial disease.
Correct Answer is D
Explanation
Choice A reason: Scheduling the next appointment for 1 year from now is a standard practice for patients who are considered to be in good health and have no immediate medical concerns. Given the patient's normal BP and BMI, along with no reported medical problems, this would typically be an appropriate action. However, it is essential to consider the patient's age and race, as African American men are at a higher risk for certain conditions, such as prostate cancer, which may warrant more frequent monitoring.
Choice B reason: While providing information for a weight loss plan that includes increasing physical activity is generally beneficial, it may not be necessary for this patient. His BMI is 24, which falls within the normal range (18.5-24.9), indicating that he is not overweight. Therefore, unless the patient expresses a desire to lose weight or improve fitness, this action might not be a priority.
Choice C reason:Offering information on reducing risk factors for hypertension is always a positive step in preventive healthcare. However, the patient's BP is 126 mm Hg, which is considered a normal reading (normal BP range is 90/60 mm Hg to 120/80 mm Hg). Therefore, while education on maintaining a healthy lifestyle is valuable, it may not be the most critical action for this visit.
Choice D reason:Scheduling a PSA test is recommended for African American men starting at age 45 due to their increased risk of prostate cancer. The PSA test measures the level of prostate-specific antigen in the blood, which can be an indicator of prostate cancer. Given the patient's demographic, this proactive screening measure is advisable, despite the absence of symptoms or previous medical problems.
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