a nurse cares for a client who has a serum potassium of 75 meql and is exhibiting cardiovascular changes which prescription should the nurse implemen
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Nursing Elites

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A client with a serum potassium of 7.5 mEq/L and cardiovascular changes needs immediate intervention. Which prescription should the nurse implement first?

Correct answer: C

Rationale: In a client with a serum potassium level of 7.5 mEq/L and cardiovascular changes, the priority intervention is to lower the potassium level quickly to prevent life-threatening complications like arrhythmias. The correct answer is to prepare to administer dextrose 20% and 10 units of regular insulin IV push. This combination helps shift potassium from the extracellular to the intracellular space, reducing serum potassium levels rapidly. Administering sodium polystyrene sulfate (Kayexalate) by mouth may take several hours to work, making it a less effective immediate intervention. Providing a heart-healthy, low-potassium diet is important for long-term management but is not the most urgent action in this situation. While hemodialysis is a definitive treatment for hyperkalemia, it is not the first-line intervention for acute management of high potassium levels with cardiovascular manifestations.

2. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)

Correct answer: A

Rationale:

3. A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?

Correct answer: B

Rationale:

4. You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

Correct answer: C

Rationale:

5. Which of the following organs does not contribute to fluid output from the body?

Correct answer: D

Rationale: The correct answer is D. All the listed organs (lungs, skin, and intestines) contribute to fluid loss from the body. Lungs contribute to fluid loss through respiration, skin through sweating, and intestines through excretion. Therefore, none of the organs listed in the options retain fluids within the body. Choices A, B, and C are incorrect because all of these organs play a role in fluid output from the body.

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