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NurseDive Free Nursing Practice Question
The nurse is reviewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L and Potassium 6.6 mEq/L. Which of the following should be the priority intervention?
A. Request a CT scan of the head.
A CT scan of the head is not indicated based on the laboratory findings provided. The priority intervention is related to the elevated potassium level.
B. Assess for Chvostek’s sign.
Chvostek’s sign is associated with hypocalcemia (low calcium levels), not hyperkalemia (high potassium levels).
C. Obtain a chest X-ray.
A chest X-ray is not the priority intervention for elevated potassium. The primary concern is the potential for cardiac arrhythmias related to the high potassium level.
D. Obtain a 12-lead ECG.
Hyperkalemia (potassium 6.6 mEq/L) can lead to cardiac arrhythmias. The nurse should obtain a 12-lead ECG to assess for any changes in the heart's electrical activity, which could indicate serious complications like arrhythmias or cardiac arrest.
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Full Explanation
A. A CT scan of the head is not indicated based on the laboratory findings provided. The priority intervention is related to the elevated potassium level.
B. Chvostek’s sign is associated with hypocalcemia (low calcium levels), not hyperkalemia (high potassium levels).
C. A chest X-ray is not the priority intervention for elevated potassium. The primary concern is the potential for cardiac arrhythmias related to the high potassium level.
D. Hyperkalemia (potassium 6.6 mEq/L) can lead to cardiac arrhythmias. The nurse should obtain a 12-lead ECG to assess for any changes in the heart's electrical activity, which could indicate serious complications like arrhythmias or cardiac arrest.
Similar Questions
A client presents to the emergency department complaining of several days of nausea and vomiting with weakness and dizziness. The client's vital signs are: Pulse 110, BP 88/56, RR 24, SpO2 95% on room air, temperature of 100.2. The client's lung sounds are clear bilaterally. Which of the following IV fluids would the nurse expect to administer?
A. Dextrose in water
Dextrose in water is typically used for hydration and to provide some calories. However, this client is presenting with hypotension (BP 88/56), tachycardia (Pulse 110), and weakness, likely due to fluid loss from vomiting. This client needs fluid resuscitation with a solution that will help restore circulating volume, and Dextrose in water does not contain sodium, which is necessary for fluid balance in this case.
B. 6.45% Sodium Chloride
6.45% Sodium Chloride is a hypertonic saline solution, which would increase the osmolarity of the blood and pull fluid into the bloodstream. This would not be the first choice for this patient, as it could exacerbate dehydration and electrolyte imbalances.
C. 10% Dextrose in water
10% Dextrose in water is also a hypertonic solution that would provide energy but would not adequately address the client's fluid volume deficit or hypotension.
D. 0.9% Sodium Chloride
0.9% Sodium Chloride is normal saline, which is an isotonic solution and is the most appropriate choice for fluid resuscitation in this client. It will help restore circulating blood volume, stabilize blood pressure, and provide the necessary hydration to address the client's symptoms of dehydration.
Full Explanation
A. Dextrose in water is typically used for hydration and to provide some calories. However, this client is presenting with hypotension (BP 88/56), tachycardia (Pulse 110), and weakness, likely due to fluid loss from vomiting. This client needs fluid resuscitation with a solution that will help restore circulating volume, and Dextrose in water does not contain sodium, which is necessary for fluid balance in this case.
B. 6.45% Sodium Chloride is a hypertonic saline solution, which would increase the osmolarity of the blood and pull fluid into the bloodstream. This would not be the first choice for this patient, as it could exacerbate dehydration and electrolyte imbalances.
C. 10% Dextrose in water is also a hypertonic solution that would provide energy but would not adequately address the client's fluid volume deficit or hypotension.
D. 0.9% Sodium Chloride is normal saline, which is an isotonic solution and is the most appropriate choice for fluid resuscitation in this client. It will help restore circulating blood volume, stabilize blood pressure, and provide the necessary hydration to address the client's symptoms of dehydration.
A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
- Determine the infusion time: The total dose is 40 mEq, and it's being infused at a rate of 10 mEq/hr.
- Therefore, the total infusion time is 40 mEq / 10 mEq/hr = 4 hours.
- Calculate the infusion rate in mL/hr: The total volume is 500 mL, and the infusion time is 4 hours.
- So, the infusion rate is 500 mL / 4 hours = 125 mL/hr.
A nurse is preparing to administer lactated Ringer's 400 mL IV bolus to infuse over 3 hr. The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
Calculate the flow rate in mL/hour: 400 mL / 3 hours = 133.33 mL/hour (approximately)
Convert the flow rate to mL/minute: 133.33 mL/hour / 60 minutes/hour = 2.22 mL/minute (approximately)
Calculate the drops per minute: 2.22 mL/minute 20 gtt/mL = 44.4 gtt/minute
Round to the nearest whole number: 44 gtt/minute