Exhibits

Review H and P, nurse's notes, laboratory results, flow sheet, and orders.

Click to mark whether the assessment finding represents a therapeutic result of the sodium bicarbonate administered, a non-therapeutic side-effect, or an unrelated finding.

A. Serum glucose level of 120 mg/dL (6.7 mmol/L):

This glucose level is within the reference range and is not directly related to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.

B. Serum ammonia level of 30 Mcg/dL (17.62 Mamal /dL):

Serum ammonia levels are not typically affected by sodium polystyrene sulfonate, and this value is within the reference range.

When administering sodium polystyrene sulfonate to a client with acute kidney injury (AKI), the medication is used to help lower elevated potassium levels (hyperkalemia). Therefore, the laboratory finding that indicates the medication has been effective is:

C. Serum potassium level of 3.8 mEq/L (3.8 mmol/L).

Explanation: Sodium polystyrene sulfonate is a medication used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, leading to the removal of excess potassium from the body through the stool. A reduction in the serum potassium level within the reference range (3.5 to 5.0 mEq/L) indicates that the medication has been effective in lowering the elevated potassium level associated with AKI.

D. Hemoglobin level of 13.5 g/dl (135 g/L):

Hemoglobin levels are unrelated to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia. This hemoglobin level is within the reference range.

When a client in the surgical recovery area asks for the largest possible dose of pain medication, the nurse should implement the following action first:

A. Ask the client to rate the current level of pain using a pain scale.

Explanation: Before administering pain medication, it is essential to assess the client's current level of pain. Using a pain scale allows the nurse to understand the severity of the pain and tailor the medication dosage accordingly. This assessment helps ensure that the client receives an appropriate and safe dose of pain medication.

Why the other choices are not the first action to take:

B. Review the history for a past use of recreational drugs:

While assessing a client's history, including past drug use, is important, it is not the immediate priority when a client is requesting pain medication. Pain assessment and management should come first.

C. Encourage the client to use diversional thoughts to manage pain:

Diversional thoughts and non-pharmacological pain management strategies can be helpful, but they should not be the initial response when a client is in acute pain and requesting medication.

D. Determine when the last dose was administered:

While it is important to know when the last dose of pain medication was given, this information is typically obtained after assessing the client's current pain level. Assessing pain intensity and then reviewing medication history and administration times is a logical sequence of actions.