25. What nursing action is appropriate if a client has a K+ of 8 mEq/L?
. No change is required in treatment.
. Restrict intake of K+ and/or give sodium polystyrene sulfonate (Kayexalate).
. Restrict fluids to reduce K+.
. Give insulin, glucose, calcium, and/or bicarbonate STAT, as ordered.
Test-Taking Tip
Know the normal ranges for common electrolytes. Recognize the dangerously high level and look for an option that will produce a change rapidly—STAT. Look at the action words: "no change required," "restrict," and "give." Choose "give."
Content Area: Adult Health, Fluid and Electrolyte Imbalances; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
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Answer 1 is incorrect because this is dangerously high potassium. It requires immediate treatment to avoid a lethal arrhythmia. Answer 2 is incorrect because restricting intake or using an ion exchange agent would reduce potassium level too slowly. Answer 3 is incorrect because fluid restriction does not reduce potassium. Answer 4 is correct because this is dangerously high potassium. Glucose, insulin, and bicarbonate help move the potassium intracellularly. Calcium helps protect the heart from hyperkalemia-induced arrhythmias.