The RN receives a call from the lab that a client's potassium chloride (KCl) level is 6.6 (normal range is 3.5 to 5 mEq/L). What should the nurse do first?
Stop the KCl infusion
Administer oral KCl
Encourage fluids for dilution
Call the pharmacy
The Correct Answer is A
Choice A reason: This is the correct answer because stopping the KCl infusion is the first and most urgent action that the nurse should take. A high level of potassium in the blood, or hyperkalemia, can cause life-threatening cardiac arrhythmias and muscle weakness. The nurse should stop the source of excess potassium, which is the KCl infusion, and monitor the client's vital signs, electrocardiogram, and symptoms.
Choice B reason: This is not the correct answer because administering oral KCl is not the first or appropriate action that the nurse should take. Oral KCl would increase the potassium level in the blood, which is already too high. The nurse should avoid giving any potassium supplements or foods that are high in potassium, such as bananas, oranges, and potatoes.
Choice C reason: This is not the correct answer because encouraging fluids for dilution is not the first or effective action that the nurse should take. Fluids alone would not lower the potassium level in the blood, but rather dilute the concentration of other electrolytes, such as sodium and calcium. The nurse should administer fluids only as prescribed by the physician, and in conjunction with other treatments, such as diuretics, insulin, or sodium bicarbonate.
Choice D reason: This is not the correct answer because calling the pharmacy is not the first or priority action that the nurse should take. Calling the pharmacy may be necessary to obtain the medications that can lower the potassium level in the blood, such as diuretics, insulin, or sodium bicarbonate. However, the nurse should first stop the KCl infusion and notify the physician, who will order the appropriate medications and dosages.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: William, who exercises three times a week, does not have a modifiable risk factor for osteoporosis. Exercise is actually beneficial for bone health, as it stimulates bone formation and reduces bone loss. Exercise also improves muscle strength, balance, and coordination, which can prevent falls and fractures.
Choice B reason: Samantha, who has a family history of osteoporosis, does not have a modifiable risk factor for osteoporosis. Family history is a genetic factor that cannot be changed or controlled. Having a parent or sibling with osteoporosis increases the risk of developing the condition, especially if they have had a fracture.
Choice C reason: Juanita, who smokes two packs of cigarettes a day, has a modifiable risk factor for osteoporosis. Smoking is a lifestyle factor that can be changed or controlled. Smoking increases the risk of osteoporosis by reducing the blood supply to the bones, decreasing the absorption of calcium, and lowering the levels of estrogen, which protects the bones.
Choice D reason: Tori, who is postmenopausal at age 40, does not have a modifiable risk factor for osteoporosis. Menopause is a natural process that occurs when the ovaries stop producing estrogen, which leads to bone loss and increased risk of fractures. Menopause cannot be prevented or reversed, but its effects on bone health can be managed with hormone therapy, calcium, and vitamin D supplements.
Correct Answer is B
Explanation
Choice A reason: Environmental stress is not the correct answer. Environmental stress is caused by external factors that are beyond the person's control, such as noise, pollution, weather, or natural disasters. These factors can affect the person's physical and mental health, but they are not related to the person's specific situation or event.
Choice B reason: Situational stress is the correct answer. Situational stress is caused by a particular situation or event that the person faces, such as a test, a job interview, a conflict, or a loss. These situations or events can create pressure, uncertainty, or anxiety for the person, and they may require the person to adapt or cope with the change or challenge.
Choice C reason: Daily Hassle stress is not the correct answer. Daily Hassle stress is caused by the minor annoyances or frustrations that the person encounters in their everyday life, such as traffic, deadlines, bills, or household chores. These hassles can accumulate and affect the person's mood, health, or well-being, but they are not related to the person's specific situation or event.
Choice D reason: Episodic stress is not the correct answer. Episodic stress is caused by frequent or chronic exposure to stressful situations or events, such as work overload, financial problems, or family issues. These situations or events can create a constant state of worry, agitation, or distress for the person, and they may affect the person's physical and mental health. Episodic stress is not a type of stress, but rather a result of experiencing too much stress over a long period of time.
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