Adaptive Quizzing - Online Flashcards
Laboratory results report a patient’s serum potassium at 5.6 mEq/L. What does the nurse immediately assess in the patient?
A. Level of consciousness
B. Heart rate
C. Bowel sounds
D. Feet for paresthesias
B. Heart rate - cardiovascular changes are a higher priority because hyperkalemia can lead to heart block
A patient is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first?
A. Blood pressure
B. Pulse
C. Respirations
D. Temperature
C. Respirations
Rationale: Respiration changes are likely because of weakness of the muscles needed for breathing. Skeletal muscle weakness results in shallow respirations.
An older adult patient is admitted with dehydration. Which nursing assessment data identify that the patient is at risk for falling?
A. Dry oral mucous membranes
B. Orthostatic blood pressures changes
C. Pulse rate of 72 and bounding
D. Serum potassium level of 4.0 mEq/L
B. Orthostatic blood pressure changes
Rationale: Blood pressure decreases when changing positions. The patient may not have sufficient blood flow to the brain, causing sensations of lightheadedness and dizziness.
A patient with hyperkalemia is being treated with drugs to improve the condition. Which potassium level indicates that therapy is effective?
A. 7.6
B. 5.6
C. 4.6
D. 2.6
C. 4.6 mEq/L
Normal ranges are 3.5 -5.0
The nurse is reviewing serum electrolytes and blood chemistry for a newly admitted patient. Which result causes the greatest concern?
A. Glucose of 97
B. Magnesium of 2.1
C. Potassium of 5.9
D. Sodium of 143
C. Potassium of 5.9
A potassium value of 5.9 mEq/L is high, and the patient should be assessed further. A glucose value of 97 mg/dL, a magnesium value of 2.1 mEq/L, and a sodium value of 143 mEq/L are normal values.
Positive Trousseau’s and Chvostek’s signs are consistent with which electrolyte imbalance?
A. Hypocalcemia
B. Hypokalemia
C. Hypercalcemia
D. Hyperkalemia
A. Hypocalcemia
Trousseau’s sign (palmar flexion) and Chvostek’s sign (facial twitching) are consistent with acute hypocalcemia. These manifestations are caused by overstimulation of the nerves and muscles.
The nurse is planning care for a patient with hypocalcemia. Which nursing action is appropriate to delegate to unlicensed assistive personnel (UAP)?
A. Collaborating with the dietitian to provide calcium-rich foods for the patient
B. Evaluating the patient’s laboratory results
C. Implementing seizure precautions for the patient
D. Transferring the patient from the bed to a stretcher using a lift sheet
D. Transferring the patient from the bed to a stretcher using a lift sheet
Transferring patients is a nursing skill that is included in UAP education and scope of practice. Collaborating with the dietitian, evaluating the patient’s laboratory results, and implementing seizure precautions all require broader education and scope of practice and should be done by licensed nursing personnel.
A patient with severe hypokalemia is prescribed parenteral administration of potassium. How does the nurse administer potassium to the patient?
A. 1 mEq of potassium to 10 mL intravenous solution
B. 10 mEq of potassium to 10 mL intravenous solution
C. 1 mEq of potassium to 10 mL solution intramuscularly
D. 10 mEq of potassium to 10 mL solution intramuscularly
A. 1 mEq of potassium to 10 mL intravenous solution
Potassium is given intravenously for severe hypokalemia, but only mixed in a solution. It is available in many concentrations. The risk of solute overload causing congested states with peripheral and pulmonary edema is directly proportional to the electrolyte concentrations of such solutions. Therefore, 1 mEq of potassium to 10 mL of solution is the preferred dilution to prevent the risk associated with hyperkalemia. A concentration of 10 mEq of potassium to 10 ml of solution is too high and can cause tissue irritation. Potassium is a severe tissue irritant; it may cause necrosis and loss of function of the tissue, and so is never given as an intramuscular or subcutaneous injection.
The health care provider writes orders for a patient who is admitted with a serum potassium (K) level of 6.9 mEq/L. What does the nurse implement first?
A. Administer sodium polystyrene sulfonate orally
B. Ensure that potassium-restricted diet is ordered
C. Place the patient on a cardiac monitor
D. Teach the patient about foods that are high in potassium
C. Place the patient on a cardiac monitor
Because hyperkalemia can lead to life-threatening bradycardia, the initial action should be to place the patient on a cardiac monitor.
The nurse instructs an older adult patient to increase intake of dietary potassium when the patient is prescribed which classification of drugs?
A. Alpha antagonists
B. Beta blockers
C. Corticosteroids
D. High-ceiling (loop) diuretics
A. High-ceiling (loop) diuretics
High-ceiling (loop) diuretics are potassium-depleting drugs. The patient should increase intake of dietary potassium to compensate for this depletion.
