A client has a serum potassium level of 2.9 mEq/L. Which action prescribed by the health care provider should the nurse take first?

Ask the patient about home insulin doses

Administer IV potassium supplements

Place the patient on a cardiac monitor

Start an insulin infusion at 0.1 units/kg/h

Answer and Explanation

The Correct Answer is B

Choice A reason: This statement is false. Asking the patient about home insulin doses is not the action that the nurse should take first. Insulin is a hormone that lowers the blood glucose level and can also lower the blood potassium level by driving potassium into the cells. However, this is not the primary cause of hypokalemia, or low blood potassium level, which can be due to other factors such as diuretics, vomiting, diarrhea, or alkalosis.

Choice B reason: This statement is true. Administering IV potassium supplements is the action that the nurse should take first. Potassium is an electrolyte that is essential for the normal function of the heart, muscles, and nerves. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis. IV potassium supplements can restore the blood potassium level and prevent life-threatening complications.

Choice C reason: This statement is false. Placing the patient on a cardiac monitor is not the action that the nurse should take first. A cardiac monitor is a device that records the electrical activity of the heart and can detect any abnormal rhythms or conduction problems. It is a useful tool for monitoring the patient's cardiac status, but it does not treat the underlying cause of hypokalemia.

Choice D reason: This statement is false. Starting an insulin infusion at 0.1 units/kg/h is not the action that the nurse should take first. Insulin infusion is a method of delivering insulin continuously through a pump or a catheter. It is used for patients with diabetes who need tight glucose control. It can also lower the blood potassium level by driving potassium into the cells. However, this is not t

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Correct Answer is C

Explanation

Choice A reason: This statement is false. 3% Sodium Chloride is a hypertonic solution that can cause fluid overload, hypernatremia, and cellular dehydration. It is not indicated for a patient with nausea, vomiting, and Salmonella infection, who is likely to have fluid and electrolyte losses.

Choice B reason: This statement is false. Dextrose 10% in water is a hypotonic solution that can cause fluid shifts, hyponatremia, and cellular edema. It is not indicated for a patient with nausea, vomiting, and Salmonella infection, who is likely to have fluid and electrolyte losses.

Choice C reason: This statement is true. 0.9% Sodium Chloride with 40 mEq Potassium (KCl) is an isotonic solution that can maintain fluid and electrolyte balance. It is indicated for a patient with nausea, vomiting, and Salmonella infection, who is likely to have fluid and electrolyte losses, especially sodium and potassium.

Choice D reason: This statement is false. Lactated Ringers is an isotonic solution that can maintain fluid and electrolyte balance, but it also contains lactate, which can be converted to bicarbonate in the liver. It is not indicated for a patient with nausea, vomiting, and Salmonella infection, who may have metabolic acidosis due to diarrhea and lactate accumulation.

A. The patient’s radial pulse is 105 beats/min B. There is sediment and blood in the patient’s urine C. There are crackles throughout both lung fields D. The blood pressure increases from 120/80 to 142/94 mm Hg

Correct Answer is C

Explanation

Choice A reason: This statement is false. The patient’s radial pulse is 105 beats/min is not the assessment data that will require the most rapid response by the nurse. A high pulse rate can indicate dehydration, anxiety, or fever, but it is not a life-threatening condition.

Choice B reason: This statement is false. There is sediment and blood in the patient’s urine is not the assessment data that will require the most rapid response by the nurse. Sediment and blood in the urine can indicate kidney damage, infection, or trauma, but they are not an immediate complication of hyponatremia.

Choice C reason: This statement is true. There are crackles throughout both lung fields is the assessment data that will require the most rapid response by the nurse. Crackles are abnormal lung sounds that indicate fluid accumulation in the alveoli, which can impair gas exchange and cause respiratory distress. Crackles can be a sign of pulmonary edema, a serious complication of hyponatremia that requires prompt treatment.

Choice D reason: This statement is false. The blood pressure increases from 120/80 to 142/94 mm Hg is not the assessment data that will require the most rapid response by the nurse. A high blood pressure can indicate fluid overload, stress, or pain, but it is not a critical condition.

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A client has a serum potassium level of 2.9 mEq/L. Which action prescribed by the health care provider should the nurse take first?

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