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: Monitoring for changes in stool color can be important when taking certain medications, but it is not specifically required for itraconazole.
Choice B reason: Drinking grapefruit juice actually increases the effects of itraconazole by inhibiting its metabolism, not reducing its effects. Therefore, patients should avoid grapefruit juice while taking itraconazole.
Choice C reason: Antacids can decrease the absorption of itraconazole, making it less effective. Patients should take itraconazole with food and an acidic drink, like cola or orange juice, but not with antacids.
Choice D reason: Reporting any difficulty with breathing is appropriate advice for any medication and does not require additional instruction.
Correct Answer is C
Explanation
Choice A reason: Obtaining vital signs every 2 hours is standard postoperative care but does not specifically address the needs of a client recovering from retinal detachment surgery.
Choice B reason: While deep breathing and coughing exercises are important postoperative interventions, they are not specific to the care of a client after retinal detachment surgery.
Choice C reason: Providing an eye shield for sleep helps to protect the eye from accidental rubbing or pressure, which is critical after retinal surgery.
Choice D reason: Teaching a family member to administer eye drops is important for ongoing care but is not as immediately critical as protecting the eye from injury.
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