A client with heart failure (HF) returns to the clinic two weeks after adjustments were made to the prescribed cardiac glycoside, diuretic, and potassium supplement. The client's lungs are clear, heart rate is 58 beats/minute, and serum potassium level is 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
Reference Range:
Potassium (K+) [3.5 to 5.0mEq/L (3.5 to 5.0 mmol/L)]
Compare the weight with what it was at last visit.
Report serum potassium to healthcare provider.
Review the dietary history from the past week.
Check the pretibial areas and ankles for edema.
The Correct Answer is B
A. While weight monitoring is important for heart failure management, it's not the priority in this situation. The low potassium level is a more immediate concern.
B. The serum potassium level of 2.9 mEq/L is significantly below the normal range and indicates hypokalemia. Hypokalemia can lead to serious cardiac arrhythmias, especially in patients taking cardiac glycosides. This is a critical finding that requires immediate attention from the healthcare provider.
C. Dietary intake can contribute to potassium levels, but it's not the most urgent action at this time.
D. Assessing for edema is important for monitoring heart failure status, but it's not the priority when there's a critical electrolyte imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. This is important to prevent injury but is not the priority at this time.
B. This is important for monitoring the seizure progression and for providing information to the healthcare provider. However, it should be done while simultaneously performing the more critical interventions of ventilation and oxygenation.
C. This is the highest priority as the client is experiencing respiratory failure with a respiratory rate of 4 breaths/minute. Providing artificial ventilation is crucial to oxygenate the patient.
D. This is not necessary at this point and may not be feasible during the emergency situation.
E. While not as immediate as BVM ventilation, increasing oxygen delivery is essential to improve oxygenation levels.
F. Begin chest compressions: Chest compressions are indicated for cardiac arrest, not respiratory failure.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
"I can stop taking the phenytoin If I go for a while and don't have a seizure." This statement indicates a lack of understanding. Anti-seizure medications are typically lifelong and should not be stopped without medical advice.
"Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not." This statement also shows a lack of understanding. A medic alert bracelet is crucial for individuals with seizures, as it provides essential information to emergency responders in case of an emergency.
"I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." This statement demonstrates a lack of understanding. Any seizure should be reported to a healthcare provider, as it could indicate changes in seizure control.
“There are really no lifestyle changes that I can do that will affect my risk for having another seizure." This statement indicates a lack of understanding. Certain lifestyle factors, such as sleep deprivation, stress, and alcohol consumption, can trigger seizures.
"I may never know why! started having seizures." This statement indicates understanding. While the cause of seizures is often unknown, it's important for the client to acknowledge this possibility.
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