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 C

Explanation

A. UTIs typically start as an ascending infection from the urethra into the bladder, not descending.
B. UTIs, especially cystitis, are generally localized infections that do not stem from infections elsewhere in the body.
C. Urinary stasis (incomplete emptying of the bladder) can lead to bacterial growth, which is a common cause of cystitis.
D. While congenital strictures can predispose to infections by causing urinary stasis, they are not the primary cause in most cases of cystitis.

A. A sonogram of the kidney B. ACT scan of the kidneys C. A midstream urine for culture D. An intravenous pyelogram for renal calculi

Correct Answer is C

Explanation

A. A sonogram may help identify kidney abnormalities but is not the initial test for suspected infection.
B. A CT scan may be needed for further evaluation but is typically not the first test ordered.
C. A midstream urine culture is often the initial diagnostic test for suspected urinary tract infections or pyelonephritis, based on symptoms of chills, fever, and flank pain.
D. An intravenous pyelogram is used to detect structural abnormalities, such as renal calculi, but is not the initial test for infection symptoms.

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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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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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