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","D","E"]
Explanation
Choice A reason: Standard precautions are always used, but a mask is not specifically required unless performing a procedure that risks splashing. MRSA is primarily spread through direct contact, so masks are not the main precaution for this client.
Choice B reason: A low bacteria diet is not typically required for MRSA or osteomyelitis management and does not directly impact the treatment or prevention of infection spread.
Choice C reason: Contact precautions are critical for preventing MRSA transmission, as it can be spread by direct contact with the infected wound or contaminated surfaces.
Choice D reason: Sending wound drainage for culture and sensitivity is crucial to identify the specific strain of MRSA and determine the most effective antibiotic treatment.
Choice E reason: Monitoring the white blood cell count is important to assess the body's response to infection and the effectiveness of treatment.
Correct Answer is D
Explanation
Choice A reason: Elevated blood pressure is a concern but not as immediately threatening as some other symptoms associated with mitral valve stenosis.
Choice B reason: A rapid, irregular heart rate could indicate atrial fibrillation, which is common in mitral valve stenosis, but it is not as urgent as blood-tinged sputum.
Choice C reason: Swollen feet and ankles suggest fluid retention, which is a concern in mitral valve stenosis but not as immediate as hemoptysis.
Choice D reason: Blood-tinged sputum indicates hemoptysis, which can be a sign of pulmonary edema or other serious complications requiring immediate intervention. This symptom is the most urgent and could signify a potentially life-threatening condition.
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