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NurseDive Free Nursing Practice Question
A nurse is assisting with preparations for administering intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L. Which of the following actions should the nurse plan to include? (Select all that apply.)
A. Repeat blood serum potassium
Repeat blood serum potassium: While it’s important to monitor potassium levels, the immediate priority when preparing to administer potassium is ensuring safe administration practices, not rechecking levels before initiating therapy.
B. Educate client regarding high-potassium food sources
Educate client regarding high-potassium food sources: Client education is important for long-term management but is not a priority when preparing for intravenous potassium replacement in an acute setting.
C. Cardiac monitoring during infusion
Cardiac monitoring during infusion: Potassium affects cardiac conduction, and rapid correction can lead to arrhythmias. Continuous cardiac monitoring is necessary to detect any life-threatening arrhythmias during the infusion.
D. Ensure that the client's urine output is at least 1 mL/kg/hour
Ensure that the client's urine output is at least 1 mL/kg/hour: Adequate urine output ensures that the kidneys are functioning and capable of excreting excess potassium, reducing the risk of hyperkalemia.
E. Ensure potassium infusion is prepared with 5% dextrose solution
Ensure potassium infusion is prepared with 5% dextrose solution: Potassium should not be mixed with dextrose, as it can increase insulin release, causing potassium to shift into cells and worsen hypokalemia.
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Full Explanation
A. Repeat blood serum potassium: While it’s important to monitor potassium levels, the immediate priority when preparing to administer potassium is ensuring safe administration practices, not rechecking levels before initiating therapy.
B. Educate client regarding high-potassium food sources: Client education is important for long-term management but is not a priority when preparing for intravenous potassium replacement in an acute setting.
C. Cardiac monitoring during infusion: Potassium affects cardiac conduction, and rapid correction can lead to arrhythmias. Continuous cardiac monitoring is necessary to detect any life-threatening arrhythmias during the infusion.
D. Ensure that the client's urine output is at least 1 mL/kg/hour: Adequate urine output ensures that the kidneys are functioning and capable of excreting excess potassium, reducing the risk of hyperkalemia.
E. Ensure potassium infusion is prepared with 5% dextrose solution: Potassium should not be mixed with dextrose, as it can increase insulin release, causing potassium to shift into cells and worsen hypokalemia.
Similar Questions
A nurse at a long-term care facility is reinforcing teaching with a newly hired nurse about the care of clients who are receiving mechanical ventilation. Which of the following information should the nurse include?
A. Reposition the client every 4 hr.
Reposition the client every 4 hr.: Repositioning should be done more frequently, typically every 2 hours, to prevent complications such as pressure ulcers.
B. Place the head of the client's bed at 40° when supine.
Place the head of the client's bed at 40° when supine: Elevating the head of the bed to 30-45° helps reduce the risk of ventilator-associated pneumonia (VAP) by preventing aspiration.
C. Turn off the ventilator alarms before suctioning the client's airway.
Turn off the ventilator alarms before suctioning the client's airway: Ventilator alarms should never be turned off as they are critical for monitoring the client's status. Alarms can be temporarily silenced, but only for the duration of the procedure.
D. Provide mouth care every 10 to 12 hr with hydrogen peroxide.
Provide mouth care every 10 to 12 hr with hydrogen peroxide: Mouth care should be provided more frequently, typically every 4 hours, to reduce the risk of infection. Hydrogen peroxide is not commonly used due to its potential to cause irritation and harm to oral tissues.
Full Explanation
A. Reposition the client every 4 hr.: Repositioning should be done more frequently, typically every 2 hours, to prevent complications such as pressure ulcers.
B. Place the head of the client's bed at 40° when supine: Elevating the head of the bed to 30-45° helps reduce the risk of ventilator-associated pneumonia (VAP) by preventing aspiration.
C. Turn off the ventilator alarms before suctioning the client's airway: Ventilator alarms should never be turned off as they are critical for monitoring the client's status. Alarms can be temporarily silenced, but only for the duration of the procedure.
D. Provide mouth care every 10 to 12 hr with hydrogen peroxide: Mouth care should be provided more frequently, typically every 4 hours, to reduce the risk of infection. Hydrogen peroxide is not commonly used due to its potential to cause irritation and harm to oral tissues.
A nurse is caring for a client who is postoperative following a tracheostomy and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?
A. Hyperventilate the client with 100% oxygen before suctioning the airway.
Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation before suctioning is a method to prevent hypoxia, not to thin secretions. It does not affect the viscosity of secretions.
B. Provide humidified oxygen.
Provide humidified oxygen: Humidified oxygen helps to moisten the airways, which can thin secretions, making them easier to clear. This is an appropriate intervention for managing tenacious secretions in a client with a tracheostomy.
C. Perform chest physiotherapy prior to suctioning.
Perform chest physiotherapy prior to suctioning: Chest physiotherapy helps mobilize secretions but does not thin them. While useful in clearing airways, it is not a direct method for thinning secretions.
D. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
Prelubricate the suction catheter tip with sterile saline when suctioning the airway: Prelubricating the suction catheter is done to reduce friction and trauma during suctioning but does not impact the thickness of the secretions.
Full Explanation
A. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation before suctioning is a method to prevent hypoxia, not to thin secretions. It does not affect the viscosity of secretions.
B. Provide humidified oxygen: Humidified oxygen helps to moisten the airways, which can thin secretions, making them easier to clear. This is an appropriate intervention for managing tenacious secretions in a client with a tracheostomy.
C. Perform chest physiotherapy prior to suctioning: Chest physiotherapy helps mobilize secretions but does not thin them. While useful in clearing airways, it is not a direct method for thinning secretions.
D. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: Prelubricating the suction catheter is done to reduce friction and trauma during suctioning but does not impact the thickness of the secretions.
A nurse is providing care to a client who has a history of asthma. The client presents with influenza symptoms that started the previous day. The provider orders an influenza test and prescribes an oral antiviral with instructions to begin the treatment as soon as possible. The client asks the nurse whether they can take the antiviral before the lab results are back. Which of the following responses by the nurse is appropriate?
A. "No, you should wait for lab confirmation because taking antivirals for a nonviral infection can increase side effects."
"No, you should wait for lab confirmation because taking antivirals for a nonviral infection can increase side effects.": While unnecessary use of antivirals can lead to side effects, prompt treatment in high-risk individuals (such as those with asthma) is crucial to mitigate complications, making this response less appropriate.
B. "No, you should wait for lab confirmation before beginning antiviral treatment, to prevent resistant viruses."
"No, you should wait for lab confirmation before beginning antiviral treatment, to prevent resistant viruses.": Delaying treatment in high-risk populations is not recommended as antivirals are most effective early in the course of the illness. This statement does not consider the urgency of treating influenza in vulnerable clients.
C. "Yes, antiviral treatment will ensure that you are less contagious and do not spread influenza to others."
"Yes, antiviral treatment will ensure that you are less contagious and do not spread influenza to others.": While antivirals can reduce viral shedding, this response overlooks the critical importance of early treatment in reducing the severity of the illness and preventing complications.
D. "Yes, antiviral treatments are most effective when they are started within 48 hours of symptom onset."
"Yes, antiviral treatments are most effective when they are started within 48 hours of symptom onset.": Antivirals are most effective when initiated within 48 hours of the onset of influenza symptoms, especially in individuals with underlying conditions like asthma. Starting treatment early can reduce the severity and duration of symptoms, making this the most appropriate response.
Full Explanation
A. "No, you should wait for lab confirmation because taking antivirals for a nonviral infection can increase side effects.": While unnecessary use of antivirals can lead to side effects, prompt treatment in high-risk individuals (such as those with asthma) is crucial to mitigate complications, making this response less appropriate.
B. "No, you should wait for lab confirmation before beginning antiviral treatment, to prevent resistant viruses.": Delaying treatment in high-risk populations is not recommended as antivirals are most effective early in the course of the illness. This statement does not consider the urgency of treating influenza in vulnerable clients.
C. "Yes, antiviral treatment will ensure that you are less contagious and do not spread influenza to others.": While antivirals can reduce viral shedding, this response overlooks the critical importance of early treatment in reducing the severity of the illness and preventing complications.
D. "Yes, antiviral treatments are most effective when they are started within 48 hours of symptom onset.": Antivirals are most effective when initiated within 48 hours of the onset of influenza symptoms, especially in individuals with underlying conditions like asthma. Starting treatment early can reduce the severity and duration of symptoms, making this the most appropriate response.