what is the priority nursing intervention for a patient with hyperkalemia what is the priority nursing intervention for a patient with hyperkalemia
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Nursing Elites

ATI RN

ATI RN Exit Exam

1. What is the priority nursing intervention for a patient with hyperkalemia?

Correct answer: A

Rationale: The correct answer is to administer calcium gluconate. In hyperkalemia, the priority is to protect the heart from potential complications like arrhythmias. Calcium gluconate is the first-line treatment as it stabilizes the cardiac cell membrane. Insulin (Choice B) and sodium bicarbonate (Choice C) can be used in conjunction with other treatments to shift potassium into cells, but calcium gluconate is the priority. Administering a diuretic (Choice D) is not the primary intervention for hyperkalemia and can even worsen the condition by reducing potassium excretion.

2. A client at 11 weeks of gestation reports slight occasional vaginal bleeding over the past 2 weeks. Following an examination, the provider informs the client that the fetus has died, indicating a:

Correct answer: Missed miscarriage

Rationale: A missed miscarriage, also known as a silent or delayed miscarriage, occurs when the embryo or fetus has died, but no bleeding or contractions have occurred to expel it from the uterus. In this scenario, the client's experiencing slight occasional vaginal bleeding over the past two weeks indicates a missed miscarriage as the fetus has died, but the body has not recognized the loss or expelled the products of conception.

3. Which of the following is not considered one of the four cornerstones or pillars in primary health care?

Correct answer: D

Rationale: The four cornerstones of primary health care are active community participation, support mechanisms made available, and the use of appropriate technology. Inter-sectoral linkages, while important, are not part of the four core pillars in primary health care.

4. Why is it difficult to get others interested in environmental health?

Correct answer: C

Rationale: The difficulty in getting others interested in environmental health is due to the fact that people tend to respond more to acute crises that receive dramatic media coverage, as opposed to chronic environmental problems that require sustained attention and action. Immediate and dramatic events capture attention more effectively than ongoing, less visible issues.

5. The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client regarding the signs and symptoms associated with dumping syndrome. Which of the following signs and symptoms, if identified by the client, indicates an understanding of this potential complication following gastrointestinal surgery?

Correct answer: D

Rationale: The correct answer is D: Diaphoresis and diarrhea. Dumping syndrome occurs after gastric surgery when food moves quickly from the stomach to the intestine, causing fluid shifts and leading to symptoms like weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain, distension, hyperactive bowel sounds, and diarrhea. Choices A, B, and C do not reflect the typical signs and symptoms of dumping syndrome.

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