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
A) Incorrect- This is true; the diaphragm should be inserted before sexual activity. However, the main concern in this scenario is the need for refitting after childbirth.
B) Incorrect- This statement is not accurate. While the diaphragm is a form of contraception, it is not considered one of the most effective methods. Long-acting reversible contraceptives
(LARCs) like intrauterine devices (IUDs) and hormonal implants are among the most effective methods.
C) Incorrect- Vaseline lubricant can be used when inserting the diaphragm: Vaseline and other oil-based lubricants can weaken the latex or cause damage to the diaphragm. Water-based lubricants are recommended for use with diaphragms.
D) Correct- The diaphragm is a barrier contraceptive device that is inserted into the vagina before sexual intercourse to prevent pregnancy. However, its effectiveness can be compromised by changes in the anatomy of the vaginal canal, cervix, and pelvic structures, such as those that occur after childbirth. After vaginal childbirth, the pelvic structures may undergo changes, including stretching and possible loss of tone. These changes can affect the fit and position of the diaphragm, leading to decreased contraceptive efficacy. Therefore, it's important for women who have given birth to have their diaphragm refitted by a healthcare provider before resuming its use.
Correct Answer is D
Explanation
The rash described, pink papular rash with vesicles, is consistent with erythema toxicum neonatorum, which is a common skin condition that affects up to 50% of newborns. It typically appears within the first few days of life and resolves without treatment within 5-7 days. The rash is benign and does not require any specific treatment or intervention.
The rash is not due to distended oil glands or a medication reaction, and there is no indication in the scenario that the healthcare provider needs to be notified about the rash. Erythema toxicum neonatorum is a self-limited condition that resolves on its own, so reassurance and education for the parents are appropriate interventions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today