A client has a serum potassium level of 6.5 mmol/L, a serum ...

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A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse?
 
  a. Place the client on a cardiac monitor immediately.
  b. Teach the client to limit high-potassium foods.
  c. Continue to monitor the client's intake and output.
  d. Ask to have the laboratory redraw the blood specimen.

Question 2

A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath.
 
  What is the nurse's priority action?
  a.
  Calculate the mean arterial pressure (MAP).
  b.
  Ask for insertion of a pulmonary artery catheter.
  c.
  Take the client's pulse.
  d.
  Slow down the normal saline infusion.

[JCABRERA33]

Answer to Question 1

ANS: A
The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.

Answer to Question 2

ANS: D
The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the client's hemodynamic status, but this should not be the initial action by the nurse. Vital signs are also important after adjusting the intravenous infusion.

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