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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: While assessing breath sounds is part of a comprehensive evaluation, it is not the most critical intervention for a TIA, which primarily affects neurological function.

Choice B reason: Palpating the suprapubic region for urinary retention is important but not the priority intervention for a client with TIA, as it does not directly relate to the risk of stroke.

Choice C reason: Reviewing the client's daily medications is necessary for overall care but is not the most immediate concern upon admission for a TIA.

Choice D reason: Initiating neurological monitoring every 2 hours is essential for a client with TIA to promptly identify any changes or progression in neurological status, which could indicate a stroke. This is the most important intervention to include in the plan of care for a client admitted with TIA. Neurological monitoring allows for immediate intervention if the client's condition worsens, potentially preventing further ischemic damage.

A. Urinary output of 30 to 60 mL/hr. B. Magnesium level. C. Size of the IV catheter. D. Serum glucose level.

Correct Answer is A

Explanation

Choice A reason: Before administering IV fluids containing potassium chloride, it is crucial to ensure that the client has adequate urinary output, typically between 30 to 60 mL/hr. This indicates good kidney function, which is necessary for the excretion of potassium to prevent hyperkalemia, a potentially life-threatening condition.

Choice B reason: While magnesium levels can affect potassium levels, they are not the most critical assessment before potassium infusion. However, it is important to monitor magnesium levels as part of the overall electrolyte balance, especially in diabetic ketoacidosis.

Choice C reason: The size of the IV catheter is important for administration purposes, but it is not the most critical assessment data before starting potassium infusion. The catheter size affects the flow rate and comfort during infusion but does not impact the decision to start the infusion.

Choice D reason: Serum glucose level is a vital parameter to monitor in diabetic ketoacidosis, but it is not the most critical assessment before starting potassium infusion. The primary concern with potassium infusion is kidney function, as assessed by urinary output.

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Naxlex Comprehensive Predictor Exams

When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is D

Explanation

A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

Correct Answer is A

Explanation

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