Nokea
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the rationale for this therapy is to:
- A. Remove the potassium from the body by renin exchange
- B. Protect the myocardium from the effects of hypokalemia
- C. Promote rapid protein catabolism
- D. Drive potassium from the serum back into the cells
Correct Answer: D
Rationale: Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.
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The nurse assesses a postoperative mastectomy client and notes the breath sounds are diminished in both posterior bases. The nurse's action should be to:
- A. Encourage coughing and deep breathing each hour
- B. Obtain arterial blood gases
- C. Increase O2 from 2-3 L/min
- D. Remove the postoperative dressing to check for bleeding
Correct Answer: A
Rationale: Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. Arterial blood gases are not indicated because there is no other information indicating impending danger. Increasing O2 rate is not indicated without additional information. Removing the dressing is not indicated without additional information.
When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
- A. Anemia and vomiting
- B. Polyuria and polydipsia
- C. Irritability relieved by feeding formula
- D. Hypothermia and azotemia
Correct Answer: B
Rationale: Anemia and vomiting are not cardinal signs of diabetes insipidus. Polyuria and polydipsia are the cardinal signs of diabetes insipidus. Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.
The client is receiving a blood transfusion. Which finding indicates a possible transfusion reaction?
- A. Temperature of 100.2°F
- B. Blood pressure of 110/70 mmHg
- C. Respiratory rate of 24 breaths per minute
- D. Itching and rash on the trunk
Correct Answer: D
Rationale: Itching and rash are signs of a possible allergic transfusion reaction, requiring immediate cessation of the transfusion. A slight temperature increase, mild hypotension, or tachypnea may occur but are less specific without other symptoms.
A client with a history of a pituitary tumor is receiving Bromocriptine (Parlodel). The nurse should monitor the client for:
- A. Hypotension
- B. Hyperglycemia
- C. Weight gain
- D. Hair loss
Correct Answer: A
Rationale: Bromocriptine, a dopamine agonist, can cause hypotension due to vasodilation. Hyperglycemia, weight gain, and hair loss are not primary side effects.
The nurse is caring for a client with a closed head injury. Which intervention is most important to prevent increased intracranial pressure (ICP)?
- A. Keep the head of the bed elevated 30–45 degrees.
- B. Administer acetaminophen for headache.
- C. Provide frequent oral care.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: Elevating the head of the bed 30–45 degrees promotes venous drainage, reducing ICP. Acetaminophen (B), oral care (C), and breathing exercises (D) are supportive but less critical for ICP control.