Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?
A. Administering a potassium-sparing diuretic.
Administering a potassium-sparing diuretic is not appropriate for a client with hyperkalemia (high potassium levels). Potassium-sparing diuretics would further increase potassium levels, worsening the condition.
B. Administering sodium polystyrene sulfonate.
Sodium polystyrene sulfonate is used to treat hyperkalemia. It works by exchanging sodium ions for potassium ions in the intestines, which helps to lower serum potassium levels by excreting it through the stool.
C. Initiating an IV potassium infusion.
Initiating an IV potassium infusion would be contraindicated in this situation as it would increase the already elevated potassium levels, potentially leading to dangerous cardiac complications.
D. Encouraging the client to eat bananas.
Encouraging the client to eat bananas is not advisable because bananas are high in potassium, which would exacerbate hyperkalemia.
This question is an excerpt from Nurse Dive's nursing test bank - ATI custom Fluid and Electrolyte Exam Summer 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice B) Administering sodium polystyrene sulfonate.
Choice A rationale:
Administering a potassium-sparing diuretic is not appropriate for a client with hyperkalemia (high potassium levels). Potassium-sparing diuretics would further increase potassium levels, worsening the condition.
Choice B rationale:
Sodium polystyrene sulfonate is used to treat hyperkalemia. It works by exchanging sodium ions for potassium ions in the intestines, which helps to lower serum potassium levels by excreting it through the stool.
Choice C rationale:
Initiating an IV potassium infusion would be contraindicated in this situation as it would increase the already elevated potassium levels, potentially leading to dangerous cardiac complications.
Choice D rationale:
Encouraging the client to eat bananas is not advisable because bananas are high in potassium, which would exacerbate hyperkalemia.
Similar Questions
A patient with atrial fibrillation and a serum potassium level of 3.0 mEq/L takes digoxin (Lanoxin), ASA (aspirin), KCL (potassium chloride), and warfarin (Coumadin) daily. The patient reports visual disturbances. The nurse suspects problems with which medication?
A. Potassium chloride.
Potassium chloride (KCL) is a supplement used to treat or prevent low potassium levels. While it can have side effects, visual disturbances are not typically associated with KCL. Therefore, it is not the medication the nurse suspects to be causing the problem.
B. Warfarin.
Warfarin (Coumadin) is an anticoagulant used to prevent blood clot formation. Visual disturbances are not a known side effect of warfarin. Therefore, it is unlikely to be the cause of the patient's symptoms.
C. Aspirin.
Aspirin (ASA) is a pain reliever and antiplatelet medication, and while it can cause visual disturbances in some cases, it is not a common or significant side effect. Aspirin is also not specifically linked to atrial fibrillation.
D. Digoxin.
Digoxin (Lanoxin) is used to treat atrial fibrillation and heart failure. Visual disturbances are a known side effect of digoxin toxicity. Given the patient's diagnosis of atrial fibrillation and the reported symptoms, the nurse suspects the problem lies with digoxin and should further investigate and report to the provider.
Full Explanation
Digoxin. Choice A rationale:
Potassium chloride (KCL) is a supplement used to treat or prevent low potassium levels. While it can have side effects, visual disturbances are not typically associated with KCL. Therefore, it is not the medication the nurse suspects to be causing the problem.
Choice B rationale:
Warfarin (Coumadin) is an anticoagulant used to prevent blood clot formation. Visual disturbances are not a known side effect of warfarin. Therefore, it is unlikely to be the cause of the patient's symptoms.
Choice C rationale:
Aspirin (ASA) is a pain reliever and antiplatelet medication, and while it can cause visual disturbances in some cases, it is not a common or significant side effect. Aspirin is also not specifically linked to atrial fibrillation.
Choice D rationale:
Digoxin (Lanoxin) is used to treat atrial fibrillation and heart failure. Visual disturbances are a known side effect of digoxin toxicity. Given the patient's diagnosis of atrial fibrillation and the reported symptoms, the nurse suspects the problem lies with digoxin and should further investigate and report to the provider.
A nurse is planning to teach a client about a high-potassium diet. Which of the following foods should the nurse instruct the client to eat? (Select all that apply.).
A. Sweet Potatoes.
Sweet potatoes are an excellent source of potassium. One medium sweet potato contains about 542 mg of potassium, making it a great option for a high-potassium diet.
B. Bananas.
Bananas are well-known for their high potassium content. A medium banana provides approximately 451 mg of potassium, which is beneficial for maintaining proper muscle and nerve function.
C. Grapes.
Grapes are not particularly high in potassium compared to other fruits. They contain some potassium, but not enough to be considered a significant source for a high-potassium diet.
D. Watermelon.
Watermelon is a good source of potassium. Two wedges of watermelon contain about 640 mg of potassium, making it a suitable choice for increasing potassium intake.
Full Explanation
The correct answer is choices A, B, and D. Here are the rationales for each choice:
Choice A rationale:
Sweet potatoes are an excellent source of potassium. One medium sweet potato contains about 542 mg of potassium, making it a great option for a high-potassium diet.
Choice B rationale:
Bananas are well-known for their high potassium content. A medium banana provides approximately 451 mg of potassium, which is beneficial for maintaining proper muscle and nerve function.
Choice C rationale:
Grapes are not particularly high in potassium compared to other fruits. They contain some potassium, but not enough to be considered a significant source for a high-potassium diet.
Choice D rationale:
Watermelon is a good source of potassium. Two wedges of watermelon contain about 640 mg of potassium, making it a suitable choice for increasing potassium intake.
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?
A. Prepare to administer a sedative.
Administering a sedative is not appropriate as the priority intervention. Sedatives can depress respiratory function, which is already compromised in this patient.
B. Prepare for mechanical ventilation.
Preparing for mechanical ventilation might be necessary if the patient’s condition worsens, but it is not the immediate priority. The priority is to identify the underlying cause of the symptoms.
C. Massage the calf area for tenderness.
Massaging the calf area for tenderness is not relevant in this context. While calf tenderness can be a sign of deep vein thrombosis (DVT), which can lead to pulmonary embolism, the immediate priority is to assess for pulmonary embolism directly.
D. Assess for indications of pulmonary embolism.
Assessing for indications of pulmonary embolism is the priority because the patient’s symptoms (shortness of breath, chest pain, recent use of birth control pills, smoking history, and abnormal ABG values) strongly suggest a pulmonary embolism. Early identification and treatment are crucial to prevent further complications.
E. None
None
F. None
None
Full Explanation
The correct answer is d. Assess for indications of pulmonary embolism.
Choice A rationale:
Administering a sedative is not appropriate as the priority intervention. Sedatives can depress respiratory function, which is already compromised in this patient.
Choice B rationale:
Preparing for mechanical ventilation might be necessary if the patient’s condition worsens, but it is not the immediate priority. The priority is to identify the underlying cause of the symptoms.
Choice C rationale:
Massaging the calf area for tenderness is not relevant in this context. While calf tenderness can be a sign of deep vein thrombosis (DVT), which can lead to pulmonary embolism, the immediate priority is to assess for pulmonary embolism directly.
Choice D rationale:
Assessing for indications of pulmonary embolism is the priority because the patient’s symptoms (shortness of breath, chest pain, recent use of birth control pills, smoking history, and abnormal ABG values) strongly suggest a pulmonary embolism. Early identification and treatment are crucial to prevent further complications.