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 D

Explanation

A. Elevated blood pressure: Hypocalcemia is more likely to cause low blood pressure due to its effect on vascular tone and cardiac contractility, not elevated blood pressure.

B. Negative Chvostek sign: A negative Chvostek sign would be expected in clients with normal calcium levels. A positive Chvostek sign (twitching of the facial muscles when tapped) is a sign of hypocalcemia.

C. Constipation: Hypocalcemia does not typically cause constipation. In fact, hypercalcemia can lead to constipation.

D. Tetany: Tetany, which involves muscle cramps and spasms, is a common manifestation of hypocalcemia. It occurs due to increased neuromuscular excitability when calcium levels are low.

A. Tap the face just below and in front of the ear. B. Inflate a blood pressure cuff around the upper arm for 4 minutes. C. Apply pressure over the ulnar and radial arteries. D. Forcefully dorsiflex the ankle when the knee is in an extended position.

Correct Answer is A

Explanation

A. Tap the face just below and in front of the ear: This is the correct technique for eliciting Chvostek’s sign, which involves tapping over the facial nerve. A positive sign (twitching of facial muscles) indicates hypocalcemia.

B. Inflate a blood pressure cuff around the upper arm for 4 minutes: This describes Trousseau’s sign, another test for hypocalcemia, where carpopedal spasm occurs due to ischemia.

C. Apply pressure over the ulnar and radial arteries: This describes Allen’s test, used to assess arterial blood flow, not calcium levels.

D. Forcefully dorsiflex the ankle when the knee is in an extended position: This describes Homan’s sign, which is used to assess for deep vein thrombosis (DVT), not hypocalcemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a calcium level of 8 mg/dL (9.0-10.5 mg/dL). Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

The nurse is using Chvostek sign to assess for hypocalcemia. Which statement correctly describes this test?

Correct Answer is A

Explanation

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