The nurse is caring for a patient with hyperkalemia.
Which of the following interventions would be appropriate?
Encouraging the patient to consume a high-potassium diet.
Administering intravenous insulin and glucose.
Administering a potassium-sparing diuretic.
Encouraging the patient to limit fluid intake.
The Correct Answer is B
This is because hyperkalemia is a condition where the blood potassium level is too high.
This can cause cardiac arrhythmias, muscle weakness, and paralysis. Therefore, the nurse should administer intravenous insulin and glucose to lower the blood potassium level by shifting it into the cells.
Choice A is wrong because encouraging the patient to consume a high- potassium diet would increase the blood potassium level and worsen the condition.
Choice C is wrong because administering a potassium-sparing diuretic would prevent the excretion of excess potassium and aggravate the hyperkalemia.
Choice D is wrong because encouraging the patient to limit fluid intake is not relevant to the management of hyperkalemia and may cause dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Daily weight.
According to MDCalc, daily weight is the most accurate indicator of fluid loss or gain in acutely ill patients, as it reflects changes in total body water.
A weight change of 1 kg corresponds to a fluid change of approximately 1 L.
Choice B is wrong because intake and output measurements can be inaccurate or incomplete, and do not account for insensible fluid losses.
Choice C is wrong because serum osmolality reflects the concentration of solutes in the blood, not the volume of fluid.
Choice D is wrong because urine specific gravity reflects the concentration of solutes in the urine, not the volume of fluid.
Correct Answer is B
Explanation
This is a priority nursing intervention for a client with acute kidney injury (AKI) because it helps to assess the renal function and fluid status of the client. Urine output is also an indicator of the response to treatment and the need for further interventions.
Choice A is wrong because pain medication is not a priority intervention for AKI unless the client has other conditions that cause pain.
Pain medication may also have adverse effects on the kidney function and should be used with caution.
Choice C is wrong because ambulation is not a priority intervention for AKI and may not be appropriate for a client who is fluid overloaded or hypotensive.
Ambulation may also increase the risk of falls and injury in a client who is confused or fatigued.
Choice D is wrong because assisting with meals is not a priority intervention for AKI and may not be necessary for a client who has adequate oral intake.
A client with AKI may also have dietary restrictions such as low protein, low potassium, low sodium, and low phosphorus, which should be considered when providing meals.
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