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 ["B","D","F"]
Explanation
As people age, the turnover of skin cells decreases, resulting in slower wound healing. This can prolong the healing process and increase the risk of complications.
The immune system's function, including T-cell function, tends to decline with age.
T-cells play a crucial role in the immune response and wound healing. Decreased T-cell function can impair the body's ability to fight infection and promote efficient healing.
With aging, there is a natural loss of subcutaneous fat, which can affect wound healing. Subcutaneous fat provides padding and protection to the underlying tissues, and its reduction can increase the risk of tissue damage and delays in healing.
Insulin resistance, pigmentation changes, and polypharmacy are not directly age-related factors that impact wound healing. Insulin resistance is a condition related to impaired glucose metabolism and can affect wound healing in individuals with diabetes or other metabolic disorders, but it is not necessarily an age-related factor. Pigmentation changes and polypharmacy (the use of multiple medications) may be associated with aging but do not directly affect the physiological processes involved in wound healing.
Correct Answer is C
Explanation
In this scenario, the child with a congenital heart defect is presenting with a fever and an
earache. The mother expresses concern about the child's weight and height being at the 5th percentile for his age. Given the child's medical history of a congenital heart defect, it is important for the nurse to address the mother's concerns and provide an accurate response.
The response that states "His smaller size is probably due to the heart disease" is appropriate because children with congenital heart defects may experience growth and developmental delays. Heart defects can affect the child's ability to obtain sufficient nutrients for growth, leading to slower weight and height gain. By acknowledging the relationship between the child's heart disease and his smaller size, the nurse provides the mother with an explanation for the child's growth pattern and helps alleviate concerns.
The other response options are not appropriate or helpful. Asking about the child's mental abilities or implying that the mother has not been feeding the child adequately can be perceived as judgmental or dismissive.
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