The healthcare provider prescribes a 5% dextrose injection 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 [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
Obtain a 12-lead electrocardiogram daily.
Evaluate glucose levels before and after meals.
Monitor and document strict intake and output.
Assess the serum potassium level every 4 hours.
The Correct Answer is D
Choice A reason: While obtaining a 12-lead electrocardiogram is important for monitoring cardiac function, it is not as frequent or specific as potassium monitoring for hyperkalemia management.
Choice B reason: Evaluating glucose levels is necessary due to the risk of hypoglycemia from insulin administration, but the priority is monitoring potassium levels in hyperkalemia.
Choice C reason: Monitoring intake and output is part of fluid balance management but is secondary to the critical need to monitor serum potassium levels.
Choice D reason: Frequent assessment of serum potassium levels is essential to evaluate the effectiveness of the dextrose and insulin therapy in lowering potassium levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Assessing body temperature is a routine post-procedure check but not the most critical for thrombocytopenia.
Choice B reason: Monitoring skin elasticity is not directly related to the risks associated with thrombocytopenia following a bone marrow biopsy.
Choice C reason: Observing the aspiration site is crucial because thrombocytopenia increases the risk of bleeding, and the site must be monitored for any signs of hemorrhage.
Choice D reason: Measuring urinary output is important but does not take precedence over monitoring the biopsy site for bleeding in a thrombocytopenic patient.
Correct Answer is D
Explanation
Choice A reason: Sudden swelling, redness, warmth, and pain are more indicative of acute conditions like deep vein thrombosis rather than chronic arterial symptoms.
Choice B reason: Weeping ulcers on lower legs are more commonly associated with venous insufficiency rather than arterial disease.
Choice C reason: Ankle edema and varicose veins are typically associated with venous disorders, not arterial disease.
Choice D reason: Intermittent claudication, which is pain during walking that subsides with rest, is a hallmark of peripheral arterial disease and is an expected finding in clients with this condition.
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