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. Checking urine for ketones is more relevant in DKA, not HHNS, as HHNS typically does not involve ketone production.
B. When blood glucose drops significantly, insulin infusion rates are usually decreased to prevent hypoglycemia and a rapid fall in glucose levels.
C. Increasing the insulin drip could cause hypoglycemia, as the client’s glucose is already decreasing.
D. A regular meal can be given when the client’s glucose levels are more stable and controlled, but meal timing should be coordinated with insulin adjustments.

A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis

Correct Answer is C

Explanation

A. Metabolic alkalosis would show a high HCO₃ level and elevated pH, which is not seen here.
B. Respiratory alkalosis would present with decreased PaCO₂ and elevated pH.
C. Metabolic acidosis is indicated by a low HCO₃ level (below 22 mEq/L) and low pH, consistent with the given values.
D. Respiratory acidosis would present with elevated PaCO₂ and a low pH, not shown in these results.

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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

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