A patient presents with severe muscle weakness and a serum potassium of 6.8 mEq/L. What is the priority nursing intervention?

Correct Answer: C

Rationale: The correct answer is C: Prepare to administer insulin and glucose. In this scenario, the patient's high serum potassium level indicates hyperkalemia, which can lead to life-threatening cardiac arrhythmias. Insulin and glucose drive potassium into the cells, lowering serum levels. Encouraging potassium-rich foods (choice A) would worsen hyperkalemia. Administering IV fluids with potassium (choice B) would further increase potassium levels. Diuretics (choice D) do not directly lower potassium levels. Administering insulin and glucose is the priority intervention to address the hyperkalemia and prevent complications.

Correct Answer: B

Rationale: The correct answer is B: Administer hypertonic IV fluids. In hyponatremia (low serum sodium level), hypertonic IV fluids help raise sodium levels gradually to prevent rapid correction and avoid complications like cerebral edema. Administering hypotonic IV fluids (choice A) can worsen the condition by further diluting sodium levels. Restricting fluid intake (choice C) may not address the underlying electrolyte imbalance. Administering potassium supplements (choice D) is not appropriate for hyponatremia.

Correct Answer: A

Rationale: The correct answer is A: Cellular destruction. Severe burns can lead to significant tissue damage, causing intracellular potassium to leak into the bloodstream, resulting in hyperkalemia. Increased dietary intake of potassium (Choice B) would not cause such a rapid rise in serum potassium levels. Diuretic therapy (Choice C) typically leads to potassium loss, not hyperkalemia. Excessive vomiting (Choice D) can result in hypokalemia due to potassium loss, not hyperkalemia. In this case, the most likely cause of hyperkalemia in a patient with severe burns is the release of potassium from damaged cells into the bloodstream.

Correct Answer: D

Rationale: The correct answer is D: Diffusion. Diffusion is the passive transport process where ions move from an area of higher concentration to an area of lower concentration until equilibrium is reached. This aligns with the scenario described in the question where ions equalize their concentration. Osmosis (A) specifically refers to the movement of water molecules across a selectively permeable membrane. Filtration (B) involves the movement of solutes through a membrane due to pressure differences. Titration (C) is a laboratory technique used to determine the concentration of a substance in a solution and is not related to passive transport processes like diffusion.

Correct Answer: B

Rationale: The correct answer is B: Check for urine output of at least 30 mL/h. Prior to hanging an IV bag containing potassium, it is crucial to ensure an adequate urine output to prevent the risk of hyperkalemia. Potassium is excreted primarily through urine, so monitoring urine output helps assess kidney function and the ability to eliminate potassium efficiently. Low urine output could indicate potential kidney issues, increasing the risk of potassium buildup in the body. Incorrect choices: A: Verify a blood pressure of at least 60 mm Hg diastolic - While blood pressure is important for assessing perfusion, it is not directly related to potassium administration. C: Ensure filter placement on the IV line - While filter placement is important for preventing particulate matter from entering the bloodstream, it is not directly related to potassium administration. D: Verify a pulse of at least 50 beats per minute - Although pulse rate is essential for assessing cardiac function, it is not specifically related to potassium administration.