Category 1
A client with a small-bowel obstruction has a nasogastric tube inserted for gastric decompression. Following insertion, the client reports mild throat discomfort and has a brief episode of coughing. The tube is secured at the prescribed insertion length, and the nurse obtains a small amount of greenish fluid that appears consistent with gastric contents. The client’s respiratory rate and oxygen saturation are currently within expected limits.
The provider then prescribes an oral medication to be administered through the nasogastric tube. Which action should the nurse take before administering the medication?
A. Aspirate gastric contents and verify that the amount and appearance are consistent with gastric secretions.
B. Inject air through the tube while auscultating over the epigastrium for the presence of a whooshing sound.
C. Obtain radiographic confirmation of the tube’s initial placement according to institutional policy.
D. Flush the tube with sterile water and assess whether the client develops coughing, dyspnea, or a change in oxygen saturation.
Answer: C
Rationale: Radiographic confirmation is required to verify initial NG-tube placement before the tube is used for medications or feeding. Green drainage, the expected insertion length, and stable oxygen saturation do not reliably confirm that the tube is positioned in the stomach. Air insufflation with auscultation is also unreliable. Because medication administration could cause serious harm if the tube is inadvertently positioned in the respiratory tract, the nurse must verify initial placement before using it.
A client with atrial fibrillation is prescribed digoxin. Before administering the medication, which findings should the nurse evaluate for digoxin safety and toxicity risk? Select all that apply.
A. Apical heart rate and rhythm
B. Serum potassium level
C. Renal function and serum creatinine
D. Digoxin serum concentration when clinically indicated
E. Liver function tests, including AST and ALT
F. Current medication profile for potential drug interactions
Answer: A, B, C, D, F
Rationale: Digoxin can cause bradycardia, making the apical heart rate and rhythm important to assess. Hypokalemia increases the risk of digoxin toxicity, and impaired renal function can decrease digoxin clearance. A serum digoxin level may be obtained when clinically indicated, particularly when toxicity is suspected. The medication profile should be reviewed for interactions that may increase digoxin levels or toxicity. Liver function tests are not a primary assessment for safe digoxin administration.
A client with a central venous catheter suddenly develops dyspnea and sharp chest pain immediately after the catheter is disconnected from the IV tubing during a tubing change. Which action should the nurse take first?
A. Place the client on the left side with the head of the bed lowered and notify the rapid response team
B. Flush the catheter with normal saline
C. Remove the catheter immediately
D. Increase the infusion rate to restore circulating volume
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Answer: A
Short rationale: Sudden dyspnea and chest pain immediately after the central line is opened or disconnected raise concern for an air embolism. Positioning the client on the left side with the head lowered may help prevent air from entering the pulmonary circulation while emergency assistance is obtained. Flushing or increasing the infusion can worsen the situation, and the catheter should not be removed independently.
A nurse is preparing to establish peripheral IV access for a hospitalized adult who is receiving IV antibiotics expected to continue for 4 days. The client is right-handed and has several potential sites. Assessment findings include:
Which site should the nurse select for the peripheral IV?
A. Left antecubital vein because its larger diameter will provide the most reliable access for IV antibiotics
B. Right hand vein because distal veins should always be selected before proximal veins
C. Right forearm vein because it provides an appropriate upper-extremity site while avoiding a joint and preserving more distal sites
D. Left forearm vein because the bruised area does not involve the vein itself
Answer: C
Rationale: The right forearm provides an appropriate upper-extremity site, with a straight, palpable vein and no indication of impaired skin integrity. A site that does not cross a joint is preferable for catheter stability and patient mobility. The nurse should generally preserve distal sites when possible, but the smallest distal vein is not automatically the best choice when a suitable forearm vein is available
A client is recovering after a colonoscopy performed with moderate sedation. Fifteen minutes after the procedure, the client is drowsy but initially responds to verbal stimulation. The nurse notes the following:
Five minutes later, the client no longer responds to verbal stimulation, has shallow respirations at 8/min, and the SpO₂ has decreased to 87%.
Which action should the nurse take first?
A. Apply supplemental oxygen and continue monitoring the client closely for improvement.
B. Attempt to awaken the client with verbal and tactile stimulation while assessing airway patency and respiratory effort.
C. Reposition the client, open the airway, and provide assisted ventilation as needed while activating the appropriate emergency response.
D. Administer oral fluids once the client is sufficiently awake to prevent dehydration after the procedure.
E. Document prolonged sedation as an expected effect and reassess the client in 15 minutes.
Answer: C
Short rationale: The client has progressed from possible partial upper-airway obstruction and hypoventilation to significant respiratory depression, demonstrated by inability to respond, shallow respirations, and falling SpO₂. The immediate priority is to open and maintain the airway and support ventilation, including assisted ventilation if needed. Supplemental oxygen alone does not correct inadequate ventilation.
A client with an indwelling urinary catheter has had no urine output for 2 hours. Which action should the nurse take first?
A. Remove the catheter
B. Irrigate the catheter routinely
C. Assess the tubing
D. Increase IV fluids
Answer: C.
Short rationale: First assess for a mechanical obstruction such as kinking or dependent loops and assess the client's overall condition.
A client with atrial fibrillation has been taking warfarin as prescribed. The nurse reviews the laboratory results and notes that the client’s INR is 4.8; the prescribed therapeutic range is 2.0–3.0.
Which action should the nurse take first?
A. The dose will need to be Increased because the client is receiving warfarin for stroke prevention.
B. Notify the provider of the INR to determine whether the warfarin dose should be held or adjusted.
C. Instruct the client to increase dietary vitamin K intake and continue the prescribed warfarin regimen.
D. Hold the next scheduled dose of warfarin and recheck the INR before administering another dose.
Answer: B
Rationale: An INR of 4.8 is above the therapeutic range and increases the client’s risk for bleeding. The nurse should notify the provider promptly so the anticoagulation regimen can be evaluated and an appropriate dose adjustment or temporary hold can be determined. The nurse should not independently alter the warfarin regimen. Consistency with vitamin K intake is generally preferred rather than making a sudden dietary change to counteract an elevated INR.
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Fifteen minutes after a packed RBC transfusion begins, a client reports low back pain and dark red urine in the urinary catheter. The client reports feeling increasingly anxious. Which action should the nurse take first?
A. Obtain a urine specimen to evaluate for hemoglobinuria
B. Stop the transfusion immediately and maintain IV access with 0.9% sodium chloride using new tubing
C. Continue the transfusion at a slower rate
D. Notify the provider and blood bank, then obtain repeat vital signs before stopping the transfusion
E. Increase the IV fluid rate through the existing blood tubing
Answer: B
Rationale: Fever, chills, severe back/flank pain, hypotension, and hemoglobinuria shortly after starting the transfusion strongly suggests an acute hemolytic transfusion reaction. The priority is to stop the transfusion immediately and maintain IV access with compatible fluid through new tubing. Diagnostic testing and notification of the provider/blood bank are important but occur after stopping the transfusion. Acetaminophen does not address the potentially life-threatening reaction.
A client with acute leukemia has a platelet count of 18,000/mm³. During the shift, the nurse notes new petechiae and oozing from the gums. Thirty minutes later, the client reports a new severe headache and nausea. Vital signs are BP 96/58 mm Hg, HR 112/min, RR 20/min, and SpO₂ 98% on room air. Which action should the nurse take first?
A. Implement bleeding precautions
B. Assess the client's neurologic status immediately
C. Recheck the platelet count before taking further action
D. Prepare the client for platelet transfusion because the platelet count is below 20,000/mm³
Answer: B
Rationale: A platelet count of 18,000/mm³ places the client at significant risk for spontaneous bleeding. The new severe headache, nausea, and change in vital signs raise concern for potentially life-threatening intracranial bleeding. The nurse should perform an immediate neurologic assessment and escalate care. Routine bleeding precautions remain appropriate, but they do not take priority over a possible acute intracranial hemorrhage. Platelet transfusion decisions depend on the clinical situation and underlying cause rather than the platelet count alone.
A client is admitted with an acute pulmonary embolism confirmed by CT pulmonary angiography. The client suddenly becomes more dyspneic and reports substernal chest pressure. Assessment findings are:
The nurse notes that the client has already received the prescribed initial anticoagulant therapy.
Which action is the nurse's priority?
A. Increase supplemental oxygen and reassess the client's oxygen saturation after 5 minutes.
B. Prepare the client for urgent reperfusion therapy while activating the appropriate emergency response.
C. Place the client in a high-Fowler position and encourage slow, controlled breathing to decrease oxygen demand.
D. Obtain a repeat echocardiogram to evaluate right ventricular function before initiating additional treatment.
Answer: B
Short rationale: The client has an acute PE with hypotension, tachycardia, hypoxemia, altered mental status, cool clammy skin, and oliguria, indicating severe hemodynamic compromise consistent with obstructive shock. Anticoagulation prevents clot extension but does not rapidly relieve an obstructing clot causing cardiovascular collapse. The client requires immediate escalation and evaluation for reperfusion therapy, such as systemic thrombolysis or another emergent intervention. Oxygen and positioning are supportive but should not delay definitive treatment.
A client with peripheral arterial disease (PAD) is 6 hours postoperative following a total hip replacement. The provider prescribes intermittent pneumatic compression (IPC) devices for venous thromboembolism prophylaxis. The client reports bilateral foot numbness compared with the preoperative assessment.
Which action should the nurse take first?
A. Apply the IPC devices as prescribed and reassess lower-extremity circulation after 15 minutes.
B. Assess bilateral pedal pulses and sensory and motor function before applying the devices.
C. Elevate both lower extremities above heart level to reduce postoperative edema before applying the devices.
D. Apply the IPC device to the unaffected leg while notifying the provider about the findings in the affected leg.
Answer: B
Rationale: The client has new findings suggesting impaired arterial perfusion—coldness, numbness, delayed capillary refill, and a diminished pedal pulse. These findings require immediate assessment before applying compression. IPC may be contraindicated or require modification when significant arterial insufficiency is present. The nurse should establish the current neurovascular status and promptly address the change rather than applying compression and potentially worsening impaired perfusion
The nurse is reviewing medication-safety considerations for a 75-year-old patient before administering prescribed medications.
For each finding, indicate whether it is Indicated to Monitor or Not Specifically Indicated to Monitor when assessing the effects of age-related physiological changes on medication safety.
Finding "Indicated to Monitor" or "Not Specifically Indicated to Monitor"
A. Increased eGFR
B. Decreased hepatic function that may impair drug metabolism
C. Increased gastric emptying and gastrointestinal motility
D. Decreased total body water and lean body mass
E. Decreased serum albumin when the medication is highly protein-bound
F. Increased hepatic blood flow
Answer:
Short rationale: Aging can alter all four components of ADME—absorption, distribution, metabolism, and excretion. Older adults may have slower GI motility, decreased total body water and lean mass, decreased hepatic metabolism, and decreased renal clearance. Reduced albumin can increase the free concentration of highly protein-bound medications. Hepatic blood flow generally decreases with aging, so increased hepatic blood flow is not an expected age-related change.
A client receiving total parenteral nutrition (PN) suddenly becomes confused and diaphoretic. The infusion pump shows that the PN bag has finished, and the next bag is not available. The client has a central venous catheter with another prescribed IV solution available. What is the nurse's priority action?
A. Restart the PN infusion at the previous rate when the next bag becomes available to prevent a rapid glucose increase
B. Check the blood glucose and follow the prescribed protocol for interruption of PN
C. Increase the rate of the remaining IV solution to compensate for the calories no longer being provided by PN
D. Administer oral carbohydrates and reassess the client's mental status before checking the blood glucose
E. Clamp the central venous catheter until the replacement PN bag arrives to prevent further metabolic changes
Answer: B
Short rationale: Abrupt interruption of dextrose-containing PN can cause rebound hypoglycemia, particularly in clients receiving continuous PN. Confusion and diaphoresis are concerning manifestations. The nurse should check the blood glucose immediately and implement the prescribed protocol for interrupted PN, which may include dextrose-containing IV fluids.
A nurse performs a focused respiratory assessment on a client with COPD who reports, “I am more short of breath than usual.” The client is sitting upright and using pursed-lip breathing. The respiratory rate is 28/min, SpO₂ is 90% on the client's usual 2 L/min oxygen, and the client is able to speak in full sentences. The nurse notes diminished breath sounds bilaterally with expiratory wheezing, consistent with the client's previous assessments.
During reassessment 20 minutes later, the respiratory rate is 32/min, SpO₂ is 88% on the same oxygen flow rate, the client is now using accessory muscles, and the client responds to questions with only short phrases.
Which finding requires the nurse's most immediate follow-up?
A. Expiratory wheezing with diminished breath sounds bilaterally
B. SpO₂ of 88% while receiving the client's usual oxygen flow rate
C. The client's inability to speak in full sentences combined with increasing work of breathing
D. Pursed-lip breathing with a respiratory rate of 32/min
Answer: C
Rationale: The most concerning finding is the progressive increase in work of breathing accompanied by a declining ability to speak, which indicates worsening respiratory distress and possible impending respiratory failure. COPD clients may have chronically abnormal breath sounds and oxygen saturation, so the nurse must interpret findings in relation to the client's baseline and trends. Increasing accessory muscle use, worsening dyspnea, and inability to speak normally are important signs of deterioration.
A client with suspected sepsis has a temperature of 39.2°C (102.6°F), HR 124/min, BP 88/52 mm Hg, and new confusion. The provider prescribes two sets of blood cultures followed by broad-spectrum IV antibiotics. The nurse prepares to obtain the cultures.
Which actions are appropriate? Select all that apply.
A. Obtain the blood cultures from two separate venipuncture sites when feasible.
B. Delay the first antibiotic dose until blood cultures are obtained even if obtaining vascular access becomes unexpectedly difficult.
C. Obtain the blood cultures before administering the first antibiotic dose, provided collection does not cause a significant delay in treatment.
D. Disinfect the blood-culture bottle tops according to institutional procedure before transferring the blood into the bottles.
E. Cleanse the collection sites with the facility-approved antiseptic and allow the antiseptic to dry before venipuncture.
Answer: A, C, D, E
Rationales
A. Correct. When feasible, obtaining each blood culture set from a separate venipuncture site helps reduce the likelihood that contamination from one site will be mistaken for a true bloodstream infection.
B. Incorrect. Blood cultures should be obtained before antibiotics when feasible, but cultures should not delay urgently needed antibiotic therapy in a client with suspected sepsis and hemodynamic instability. If obtaining cultures becomes unexpectedly difficult, treatment should not be significantly delayed.
C. Correct. Blood cultures are ideally obtained before the first antibiotic dose because antimicrobial therapy can reduce the number of organisms available for detection and may decrease the likelihood of identifying the causative pathogen. However, obtaining cultures should not cause a significant delay in treatment.
D. Correct. Disinfecting the blood-culture bottle tops according to institutional procedure helps prevent microorganisms from contaminating the specimen during transfer and improves the accuracy of culture results.
E. Correct. Proper skin antisepsis and allowing the antiseptic to dry before venipuncture help reduce contamination of the blood specimen and decrease the risk of a false-positive culture.
The provider prescribes heparin at 18 units/kg/hr for a client weighing 82 kg. The available infusion contains 25,000 units in 500 mL. How many mL/hr should the nurse program?
A. 14.8 mL/hr
B. 24.6 mL/hr
C. 29.5 mL/hr
D. 36.9 mL/hr
Answer: C — 29.5 mL/hr.
Short rationale:
18 × 82 = 1,476 units/hr.
25,000 ÷ 500 = 50 units/mL.
1,476 ÷ 50 = 29.52 mL/hr, rounded to 29.5 mL/hr.
The nurse is preparing to administer IV insulin to a client with diabetic ketoacidosis (DKA). Which actions are appropriate for safe administration? Select all that apply.
A. Verify that regular insulin is prescribed for IV administration.
B. Verify the insulin concentration and prescribed infusion rate before administration.
C. Use insulin lispro if rapid glucose reduction is needed.
D. Independently verify the high-alert medication according to institutional policy.
E. Monitor serum potassium throughout therapy.
F. Monitor blood glucose at the prescribed frequency and adjust therapy according to the DKA treatment protocol.
Answer: A, B, D, E, F
Short rationale: Regular insulin is used for IV insulin therapy in DKA and allows rapid titration. Safe administration requires verification of the insulin concentration and rate, appropriate high-alert medication checks, and frequent glucose monitoring. Potassium must be monitored because insulin shifts potassium into cells and can cause hypokalemia. Insulin lispro is not substituted for IV regular insulin in the standard DKA protocol.
A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving high-flow nasal cannula oxygen on a medical-surgical unit. The patient suddenly develops severe shortness of breath, and the oxygen saturation drops from 94% to 82%. The nurse notes absent breath sounds over the right lung, tachycardia, and decreasing blood pressure.
Which action should the nurse take first?
A. Suction the patient's airway and administer a prescribed bronchodilator.
B. Request a stat portable chest X-ray before initiating further interventions.
C. Activate the rapid response team and prepare for emergency pleural decompression.
D. Increase the oxygen flow rate and reassess the patient's respiratory status in 15 minutes.
Correct answer: C
Rationale: The sudden onset of severe dyspnea, unilateral absent breath sounds, hypoxemia, tachycardia, and hypotension suggests a tension pneumothorax. Air accumulating in the pleural space can compress the affected lung and impair venous return, causing cardiovascular instability.
A: Suctioning and bronchodilators may help with airway obstruction or bronchospasm but do not treat the suspected underlying emergency.
B: Imaging must not delay emergency intervention when tension pneumothorax is suspected in an unstable patient.
C: Correct. Activate the rapid response team immediately and prepare for emergency needle or finger decompression followed by chest tube placement by a qualified clinician.
D: Supplemental oxygen is appropriate, but waiting 15 minutes risks further deterioration.
Teaching point: The key clues are sudden respiratory deterioration + absent unilateral breath sounds + hypotension. Students should recognize a possible tension pneumothorax and prioritize emergency escalation rather than waiting for diagnostic confirmation.
A client with a history of heart failure suddenly reports palpitations, chest pressure, and dizziness. The cardiac monitor shows a rapid, irregularly irregular rhythm at 168/min. The nurse obtains a blood pressure of 78/46 mm Hg. The client is pale, diaphoretic, and increasingly confused. Which action should the nurse take first?
A. Obtain a 12-lead ECG to identify the specific dysrhythmia.
B. Prepare the client for synchronized cardioversion while activating the appropriate emergency response.
C. Administer the prescribed IV beta-blocker to slow the ventricular rate.
D. Notify the provider that the client may have new-onset atrial fibrillation and await further orders.
Answer: B
Rationale: The client has a rapid dysrhythmia with hypotension, altered mental status, chest pressure, and poor perfusion, indicating hemodynamic instability. When a tachydysrhythmia is causing instability and the rhythm is amenable to synchronized cardioversion, immediate synchronized cardioversion is the priority. Obtaining additional diagnostic information or administering a rate-control medication should not delay treatment of an unstable client.
A client has a postoperative abdominal wound with increasing redness, warmth, tenderness, and a small amount of purulent drainage. The provider orders a wound culture. Which action should the nurse take to obtain the most clinically useful specimen?
A. Swab the surface of the wound where the drainage is most visible before cleansing the wound.
B. Cleanse the wound according to the prescribed procedure, then collect a specimen from viable tissue or fresh drainage using the facility-approved collection technique.
C. Irrigate the wound with sterile saline and collect the specimen from the remaining drainage without disturbing the wound bed.
D. Apply sterile gauze to the wound, allow it to absorb fresh drainage, and use the drainage from the gauze to obtain the specimen.
Answer: B
Rationale
B. Correct. The specimen should best represent microorganisms associated with the infected wound tissue, rather than organisms present on the superficial wound surface. After appropriate cleansing, the nurse collects fresh drainage or obtains a specimen from viable tissue using the facility-approved technique.
A. Incorrect. The surface of a wound may contain normal skin flora and colonizing organisms that do not represent the cause of the infection. Cleansing the wound before specimen collection helps reduce contamination from superficial organisms.
C. Incorrect. Although wound irrigation may be part of wound care, collecting only residual drainage without obtaining a specimen from the appropriate wound tissue may produce a less representative sample. The specimen should be collected using the specific technique ordered or approved by the facility.
D. Incorrect. Drainage absorbed into gauze may contain organisms from the wound surface and surrounding environment and is not an appropriate substitute for collecting a fresh specimen directly from the wound using the prescribed technique.
A nurse scans a client's medication barcode and receives an alert stating that the medication does not match the prescribed medication. What should the nurse do?
A. Override the alert because the medication is correct
B. Administer the medication if the client recognizes the tablet
C. Stop and verify the medication against the original order before administration
D. Ask another nurse to administer it instead
Answer: C.
Short rationale: A barcode mismatch is a medication-safety warning. The nurse must stop and verify the medication against the order.
A client receives IV furosemide for acute pulmonary edema. Which finding best indicates that the medication is producing the desired therapeutic response?
A. Decreased jugular venous distention
B. Decreased oxygen requirement and improved work of breathing
C. Increased bilateral crackles
D. Decreased dependent edema
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Answer: B
Rationale: In acute pulmonary edema, the priority therapeutic outcome is improved oxygenation and respiratory status as excess fluid is removed. Decreased JVD and dependent edema may occur with diuresis but are less immediate indicators of improvement in pulmonary edema. Increased crackles indicate worsening pulmonary congestion.
A client is receiving IV potassium chloride through a peripheral catheter. Twenty minutes after the infusion begins, the client reports increasing burning and tightness at the IV site. The nurse notes swelling, blanching, and coolness of the surrounding skin. The infusion pump is alarming for increased resistance. Which actions should the nurse take? Select all that apply.
A. Restart the infusion through the same catheter at a slower rate after the burning subsides.
B. Follow the institution's extravasation protocol for potassium-containing medications before removing the catheter.
C. Notify the provider based on the severity of the tissue injury and institutional protocol.
D. Flush the catheter with normal saline to dilute any potassium remaining in the tissue.
E. Stop the potassium infusion immediately.
F. Remove the catheter immediately and apply pressure to the site
G. Assess the affected extremity and determine whether the findings are consistent with infiltration or extravasation.
Answer: B, C, E, G
Short rationale: Burning, swelling, blanching, coolness, and increased resistance are concerning for IV infiltration/extravasation. Potassium can cause significant tissue injury when it enters surrounding tissue. Stop the infusion, assess the site, and follow the medication-specific extravasation protocol before manipulating or removing the catheter. The catheter may need to remain in place temporarily for aspiration of residual medication, depending on institutional protocol. Do not flush the catheter or restart the infusion through the affected site.
A client is scheduled for a major abdominal surgery and is participating in preoperative teaching. The client asks, “What can I do after surgery to reduce my risk of pneumonia, blood clots, and problems with my incision?”
Which instructions should the nurse include? Select all that apply.
A. Use the incentive spirometer regularly while awake and perform slow, sustained inhalations rather than rapid, shallow breaths.
B. Support the abdominal incision with a pillow during coughing or deep-breathing exercises, but continue to cough as instructed.
C. Remain in bed until the first postoperative assessment confirms that ambulation is safe.
D. Avoid coughing during the first 24 hours because increased abdominal pressure can disrupt the surgical incision.
E. Report new discomfort behind one knee
Answer: A, B, C, E
Short rationale: Effective postoperative teaching emphasizes lung expansion, secretion clearance, venous circulation, early mobility, and incision support. Incentive spirometry and coughing/deep breathing help prevent atelectasis and pneumonia. Splinting supports the incision without suppressing coughing. Leg exercises and early ambulation reduce venous stasis. New unilateral calf symptoms or sudden dyspnea/chest pain may indicate DVT/PE and require prompt evaluation. Bed rest, avoiding coughing, and unprescribed oral fluids can increase risk or conflict with postoperative restrictions.
A client with chronic kidney disease has a serum potassium level of 6.8 mEq/L (6.8 mmol/L) and peaked T waves with a widening QRS complex. The client receives IV calcium gluconate, regular insulin with IV dextrose, and a potassium binder. The nurse reassesses the client after treatment.
Which findings indicate that the client's response to treatment is improving? Select all that apply.
A. The QRS complex narrows and the previously peaked T waves begin to resolve.
B. The serum potassium decreases from 6.8 to 5.4 mEq/L (5.4 mmol/L).
C. The client's blood glucose decreases from 108 to 58 mg/dL (6.0 to 3.2 mmol/L).
D. The client reports less muscle weakness and is able to move the extremities more easily.
E. The serum potassium remains at 6.8 mEq/L, but the client reports feeling less anxious.
Select all that apply.
Answer: A, B, D
Rationales
A. Correct. Narrowing of the QRS complex and improvement in peaked T waves indicate that the cardiac effects of hyperkalemia are improving. This reflects an important therapeutic response to treatment, particularly the cardiac membrane stabilization provided by IV calcium.
B. Correct. A decrease in serum potassium from 6.8 to 5.4 mEq/L indicates that the hyperkalemia is improving. Insulin with dextrose temporarily shifts potassium into cells, while the potassium binder promotes potassium removal from the body.
C. Incorrect. A blood glucose of 58 mg/dL indicates hypoglycemia, which is an adverse effect requiring intervention rather than a desired response. Dextrose is administered with insulin to reduce this risk.
D. Correct. Improvement in muscle weakness can indicate that the neuromuscular effects of severe hyperkalemia are resolving as the serum potassium decreases.
E. Incorrect. Although reduced anxiety may indicate that the client feels better, the potassium remains critically elevated. Subjective improvement does not demonstrate that the underlying hyperkalemia has been adequately treated.
Clinical judgment point: Evaluate the physiologic response, not simply whether the client says they feel better. For severe hyperkalemia, improvement in ECG changes, serum potassium, and neuromuscular manifestations provides stronger evidence that treatment is working.