A patient is transferred to the emergency department from the outpatient clinic with a diagnosis of hyperkalemia. Kayexalate was prescribed. Which of the following nursing actions will the nurse perform before administering Kayexalate?

Start IV 0.9% Sodium Chloride

Assess for bowel sounds

Start 02 at 2L/min

Assess lab value for potassium

Answer and Explanation

The Correct Answer is B

A. Starting IV 0.9% sodium chloride may be necessary for hydration but is not a priority action before administering Kayexalate.
B. Assessing for bowel sounds is essential because Kayexalate works by exchanging potassium for sodium in the intestine, and bowel motility must be adequate to ensure the medication is effective and to prevent complications such as bowel obstruction.
C. Starting oxygen is unnecessary unless the patient exhibits signs of respiratory distress, which is not indicated here.
D. While checking potassium levels is important, it is often done as part of the initial assessment and does not need to be repeated immediately before administering Kayexalate if levels were already assessed and are high.

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Correct Answer is B

Explanation

A. Preparing only 16 units would mean administering just the regular insulin and not the NPH insulin, which is also prescribed.
B. The total number of insulin units is calculated by adding the units of regular insulin (16 units) and NPH insulin (26 units), resulting in 42 units to be administered together.
C. Preparing only 26 units would mean administering only the NPH insulin and not the regular insulin, which is not appropriate.
D. Preparing 32 units is incorrect as it does not accurately reflect the sum of both insulin types prescribed.

A. Irrigate the catheter. B. Check the tubing for kinks. C. Notify the provider. D. Adjust the rate of the bladder irrigant.

Correct Answer is B

Explanation

A. Irrigating the catheter may be necessary, but the nurse should first assess for a simpler cause of the obstruction, such as a kink.
B. Checking for kinks is the priority, as it is a common cause of catheter obstruction and can be easily corrected.
C. Notifying the provider is unnecessary unless troubleshooting measures fail to resolve the issue.
D. Adjusting the bladder irrigant rate may be considered, but only after ensuring the tubing is free from kinks.

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A patient is transferred to the emergency department from the outpatient clinic with a diagnosis of hyperkalemia. Kayexalate was prescribed. Which of the following nursing actions will the nurse perform before administering Kayexalate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has diabetes and a new prescription for 16 units of regular insulin and 26 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?

Correct Answer is B

Explanation

A nurse is caring for a client who is 6hrs postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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