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. Retinopathy involves the retina and is detected through eye exams, not monofilament testing.
B. Neuropathy is the correct answer, as monofilament testing assesses sensation loss in peripheral neuropathy.
C. Radiculopathy relates to nerve root issues in the spine, not typically assessed with monofilaments.
D. Nephropathy concerns kidney function and is not assessed via sensory testing in the extremities.

A. Glycosylated hemoglobin A1C B. Urine dipstick for glucose. C. Fasting blood glucose D. Oral glucose tolerance

Correct Answer is A

Explanation

A. Glycosylated hemoglobin A1C provides an average of the patient's blood glucose levels over the past 2-3 months and is the standard test used to evaluate long-term glycemic control in patients with diabetes.
B. A urine dipstick for glucose measures glucose in the urine but does not provide an accurate assessment of overall blood glucose control or effectiveness of treatment.
C. Fasting blood glucose is useful for assessing current blood sugar levels but does not reflect long-term management or control.
D. An oral glucose tolerance test is typically used for diagnosing diabetes rather than for ongoing monitoring of treatment effectiveness.

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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 B

Explanation

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Correct Answer is A

Explanation

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