A nurse is reviewing the medical record of a client and identifies a serum potassium 6.8 mEq/L (3.5-5 mEq/L). Which of the following medications should the nurse expect to administer?

Lactulose

Acetylcysteine

Sodium polystyrene (Kayexalate)

Triamterene

Answer and Explanation

The Correct Answer is C

A. Lactulose: Lactulose is used to treat hepatic encephalopathy by reducing ammonia levels, not for hyperkalemia.

B. Acetylcysteine: Acetylcysteine is used for acetaminophen overdose or as a mucolytic agent, not for hyperkalemia.

C. Sodium polystyrene (Kayexalate): Kayexalate is used to treat hyperkalemia by exchanging sodium for potassium in the intestines, promoting the elimination of potassium through the stool. This is the correct treatment for a potassium level of 6.8 mEq/L, which is dangerously high.

D. Triamterene: Triamterene is a potassium-sparing diuretic and would worsen hyperkalemia, not treat it.

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Correct Answer is C

Explanation

A. BP 178/90 mm Hg: High blood pressure can be seen in various conditions, including stress or pain. Dehydration typically leads to low blood pressure, not high, making this less likely to be an indicator of dehydration.

B. Red mucous membranes: Red mucous membranes can indicate a variety of conditions, including infection or inflammation, but it is not a classic sign of dehydration.

C. Skin tenting: Skin tenting, or the inability of the skin to return to normal after being pinched, is a classic sign of dehydration, particularly in moderate to severe cases. This indicates reduced skin turgor and is directly related to fluid volume depletion.

D. Jugular vein distention: Jugular vein distention is more indicative of fluid overload or increased central venous pressure, not dehydration.

A. The nurse applies a tourniquet to assess a vein. B. The nurse dons gloves before starting the IV. C. The nurse blows on the area cleansed with alcohol to dry it quickly D. The nurse cleans the area with an alcohol pad

Correct Answer is C

Explanation

A. The nurse applies a tourniquet to assess a vein: Applying a tourniquet is standard practice and does not increase infection risk if proper technique is used.

B. The nurse dons gloves before starting the IV: Wearing gloves minimizes the risk of infection for both the patient and the nurse.

C. The nurse blows on the area cleansed with alcohol to dry it quickly: Blowing on the site introduces bacteria from the nurse's breath to the cleansed area, increasing the risk of infection.

D. The nurse cleans the area with an alcohol pad: Cleaning the site with alcohol reduces the risk of infection and is standard practice.

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A nurse is reviewing the medical record of a client and identifies a serum potassium 6.8 mEq/L (3.5-5 mEq/L). Which of the following medications should the nurse expect to administer?

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