what are the key signs of hyperkalemia and how should it be treated

ATI LPN

ATI NCLEX PN Predictor Test

1. What are the key signs of hyperkalemia and how should it be treated?

A. Elevated potassium levels, muscle weakness; administer calcium gluconate
B. Decreased potassium levels, confusion; administer potassium chloride
C. Elevated sodium levels, bradycardia; administer sodium bicarbonate
D. Low sodium levels, muscle cramps; administer sodium chloride

Correct answer: A

Rationale: The correct signs of hyperkalemia include elevated potassium levels and muscle weakness. The treatment involves administering calcium gluconate to help stabilize the heart. Choice B is incorrect as hyperkalemia is characterized by elevated, not decreased, potassium levels. Choice C is incorrect as hyperkalemia does not involve elevated sodium levels, and the treatment is not sodium bicarbonate. Choice D is incorrect as hyperkalemia does not lead to low sodium levels, and sodium chloride is not the treatment for hyperkalemia.

2. A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

A. Hemoglobin A1c of 6%
B. Fasting blood glucose of 90 mg/dL
C. Blood glucose of 200 mg/dL
D. Blood glucose of 100 mg/dL

Correct answer: C

Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.

3. Which of the following is a key consideration when caring for a client with heart failure on fluid restriction?

A. Encourage the client to drink more fluids to stay hydrated
B. Weigh the client daily to monitor fluid status
C. Limit the client's intake of fruits and vegetables
D. Monitor the client's fluid intake only during meals

Correct answer: B

Rationale: When caring for a client with heart failure on fluid restriction, weighing the client daily is crucial to monitor fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluids, which can worsen heart failure. Encouraging the client to drink more fluids (choice A) contradicts the goal of fluid restriction. Limiting intake of fruits and vegetables (choice C) is not a specific guideline for managing fluid restriction in heart failure. Monitoring fluid intake only during meals (choice D) is insufficient as fluid balance needs to be monitored consistently throughout the day.

4. How should a healthcare professional assess a patient with fluid overload?

A. Monitor weight and assess for edema
B. Monitor blood pressure and auscultate lung sounds
C. Assess for jugular venous distention
D. Monitor oxygen saturation and check for fluid retention

Correct answer: A

Rationale: The correct way to assess a patient with fluid overload is by monitoring weight and assessing for edema. Weight monitoring helps in detecting fluid retention, and edema is a visible sign of excess fluid accumulation. Although monitoring blood pressure and auscultating lung sounds are important assessments in heart failure, they are not specific to fluid overload. Assessing for jugular venous distention is more indicative of right-sided heart failure rather than fluid overload. Monitoring oxygen saturation and checking for fluid retention are not primary assessments for fluid overload.

5. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following actions should the nurse take?

A. Administer insulin
B. Administer glucagon
C. Administer 4 oz of orange juice
D. Administer 1 L of water

Correct answer: C

Rationale: Administering 4 oz of orange juice is the appropriate action for a client experiencing hypoglycemia due to diabetes mellitus. Orange juice contains simple sugars that can quickly raise blood glucose levels. Insulin (Choice A) would further lower blood sugar, worsening the condition. Glucagon (Choice B) is used in severe hypoglycemia when the client cannot take anything by mouth. Administering 1 L of water (Choice D) is not indicated in hypoglycemia treatment; the priority is to raise blood sugar levels. Therefore, the correct choice is to administer orange juice to address the low blood sugar in this situation.