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: Prepare to administer dextrose 20% and 10 units of regular insulin IV push.

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. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Before her paracentesis, you instruct her to:

Correct answer: A

Rationale: Before paracentesis, instruct the patient to empty her bladder to avoid bladder injury during the procedure.

3. Vygotsky's emphasis on culture and social experience led him to __________.

Correct answer: A

Rationale: Vygotsky's emphasis on culture and social experience did not lead him to neglect the biological side of development. Instead, he believed that biological factors and social influences interact to shape cognitive development. Choice A is correct because it reflects Vygotsky's view that biological factors and social experiences work together in cognitive development. Choices B, C, and D are incorrect as Vygotsky's emphasis was not on overemphasizing heredity, focusing solely on independent efforts of children, or placing too much emphasis on children's capacity to shape their own development.

4. A nurse is reviewing the laboratory results of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: A positive antinuclear antibody (ANA) titer is a significant finding in clients with systemic lupus erythematosus (SLE) as it indicates active disease. This result should be reported to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and not specifically indicative of disease activity in SLE. Therefore, they do not require immediate reporting to the provider.

5. Which is an essential component of health literacy?

Correct answer: C

Rationale: An essential component of health literacy is the ability to navigate the health care system. This skill is crucial for individuals to access, understand, and effectively utilize health services available to them. Navigating the health care system involves understanding how to find appropriate healthcare providers, make appointments, understand insurance coverage, and follow through with treatment recommendations. Without this ability, individuals may struggle to access needed care, leading to potential negative health outcomes.

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