The nurse is caring for the client with cardiac and renal disease. The client now has a serum potassium level of 6.0 mEq/L. Which medications, if prescribed, should the nurse administer? Select all that apply.
Calcium gluconate 1.5 grams IV now
Dextrose 50% injection (50ml) IV push now
Colace 100 mg PO now
Regular insulin 10 units IV now
Potassium chloride 20 mEq orally now
Correct Answer : A,B,D
A) Calcium gluconate 1.5 grams IV now: Calcium gluconate is administered to counteract the effects of hyperkalemia by stabilizing the myocardial cell membrane. It does not lower potassium levels but helps protect the heart from potential dysrhythmias associated with high potassium levels.
B) Dextrose 50% injection (50ml) IV push now: Dextrose 50% injection, also known as D50W, is administered to temporarily shift potassium from the extracellular space into the intracellular space, thereby lowering serum potassium levels. It is commonly used in combination with insulin to facilitate the movement of potassium into cells.
C) Colace 100 mg PO now: Colace is a stool softener and does not affect serum potassium levels. It is not indicated for the treatment of hyperkalemia.
D) Regular insulin 10 units IV now: Regular insulin is administered with dextrose to facilitate the movement of potassium from the extracellular space into the intracellular space. Insulin stimulates the cellular uptake of glucose, which in turn drives potassium into cells along with glucose.
E) Potassium chloride 20 mEq orally now: Potassium chloride is contraindicated in the treatment of hyperkalemia as it would further increase serum potassium levels. It is typically used to supplement potassium in clients with hypokalemia, not hyperkalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Gloves: When removing PPE for a client requiring airborne precautions, gloves should be removed first because they are considered the most contaminated item. Removing gloves first helps prevent contamination of other PPE and the healthcare provider's hands.
B. Mask: After removing gloves, the mask should be removed by grasping the ties or ear loops without touching the front of the mask. Removing the mask prevents the potential spread of infectious agents when the client is no longer in the immediate vicinity.
C. Gown: Following the removal of the mask, the gown should be removed, taking care to avoid touching the front of the gown. Removing the gown minimizes the risk of contamination to the healthcare provider's clothing or skin.
D. Goggles: If goggles were worn as part of the PPE for airborne precautions, they should be removed last after gloves, mask, and gown. Removing goggles last helps prevent any potential contamination of the eyes during the removal process.
Correct Answer is D
Explanation
A) Administer and teach about medications to suppress stage III sleep:
Suppressing stage III sleep is not a primary intervention for sleepwalking and could potentially disrupt the client’s overall sleep quality.
B) Encourage the child to verbalize feelings regarding sleep pattern:
While understanding feelings about sleep patterns may be helpful, it is not the immediate priority in managing sleepwalking.
C) Provide a quiet environment for nighttime sleep:
A quiet environment is generally beneficial for good sleep hygiene but does not directly address the safety concerns associated with sleepwalking.
D) Maintain patient safety during episodes of somnambulism:
Ensuring the client’s safety is the primary focus. Sleepwalking can lead to accidents or injuries; therefore, implementing safety measures to prevent harm during episodes of somnambulism is crucial. This may include securing the environment, using safety gates, and ensuring the client’s immediate surroundings are safe.
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