A client’s bloodwork indicates that he has severe hypokalemia.
What is a priority nursing intervention?

This is because hypokalemia (low potassium level in the blood) can cause abnormal heart rhythms (arrhythmia) that can be life-threatening and require urgent medical attention. A cardiac monitor can help detect and treat any arrhythmia that may occur.

Choice B is wrong because administering a laxative can worsen hypokalemia by causing more potassium loss through the digestive tract. Laxative use is one of the possible causes of hypokalemia.

Choice C is wrong because placing the client on seizure precautions is not a priority intervention for hypokalemia. Seizures are not a common symptom of hypokalemia, although muscle weakness and cramps may occur.

Choice D is wrong because restricting high potassium foods is not a priority intervention for hypokalemia. In fact, increasing potassium intake through foods or supplements may be helpful in less serious cases of hypokalemia. However, this should be done according to the doctor’s recommendation and with careful monitoring of blood potassium levels.

Normal blood potassium levels for an adult range from 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than 2.5 mmol/L) can be life threatening.

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.