The healthcare provider prescribes 5% Dextrose Injection, USP with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?
Reference Range
- Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
- Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
Evaluate glucose levels before and after meals.
Assess the serum potassium level every 4 hours.
Monitor and document strict intake and output.
Obtain a 12-lead electrocardiogram daily.
The Correct Answer is B
The client's serum potassium level is elevated at 6.0 mEq/L (6.0 mmol/L), which is above the normal reference range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).
Hyperkalemia can have significant cardiac implications, including the potential for life-threatening dysrhythmias. Therefore, close monitoring of the serum potassium level is crucial to assess the effectiveness of interventions and ensure that potassium levels are within a safe range.
While monitoring glucose levels before and after meals is important for clients receiving insulin therapy, in this scenario, the primary concern is the elevated potassium level.
The nurse should prioritize frequent assessment of the serum potassium level to guide appropriate management and prevent complications associated with hyperkalemia.
Monitoring and documenting strict intake and output are important for assessing fluid balance and renal function, but in this case, the elevated potassium level takes precedence as it poses a more immediate risk to the client's well-being.
Obtaining a 12-lead electrocardiogram (ECG) daily may be indicated in some cases of hyperkalemia, as certain ECG changes can be associated with elevated potassium levels. However, the more critical aspect is monitoring the potassium level itself, as ECG changes can occur rapidly and may not always be detectable on a daily basis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Explain to the parents that anger is a common response to grief.
Choice A rationale:
Referring the parents to the chaplain for grief counseling can be beneficial, but it may not address the immediate emotional outburst and the need for understanding their feelings.
Choice B rationale:
Telling the parents that blaming each other will not change the situation might be true, but it can come across as dismissive and may not provide the emotional support they need at that moment.
Choice C rationale:
Assuring the parents that a terminal diagnosis is inevitable does not address their current emotional state and may seem insensitive to their grief and anger.
Choice D rationale:
Explaining to the parents that anger is a common response to grief helps them understand their emotions and provides immediate emotional support, making it the best intervention in this situation.
Correct Answer is A
Explanation
A) Correct- Hematocrit values below the reference range during pregnancy could indicate anemia, which requires further evaluation and intervention. The other findings can be attributed to normal physiological changes during pregnancy (elevated total T4, heart rate increase) or can be common findings (systolic murmur).
B) Incorrect - A heart rate of 92 beats per minute is within the normal range for pregnancy due to increased blood volume and hormonal changes.
C) Incorrect - A systolic murmur can be a common finding during pregnancy due to increased cardiac output.
D) Incorrect - An elevated total T4 can be a normal finding during pregnancy due to hormonal changes.
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