A nurse is assessing a patient with hypokalemia, she notes that the patient's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?
Assess the patient’s respiratory rate, rhythm, depth
Call the healthcare provider
Document findings and monitor the patient
Measure the patient’s pulse and blood pressure
The Correct Answer is A
A. Assess the patient’s respiratory rate, rhythm, depth:
This is the correct action to take first. Hypokalemia can lead to respiratory muscle weakness, which can result in respiratory compromise or failure. Assessing the patient's respiratory rate, rhythm, and depth will help determine if there are any signs of respiratory distress or impending respiratory failure.
B. Call the healthcare provider:
While it's important to involve the healthcare provider, especially if there is a significant change in the patient's condition, assessing the patient's immediate respiratory status takes priority to ensure prompt intervention if respiratory distress is present.
C. Document findings and monitor the patient:
Documenting findings and ongoing monitoring are essential steps, but they come after addressing the patient's immediate needs, such as assessing respiratory status in this case.
D. Measure the patient’s pulse and blood pressure:
While vital signs are important, they may not immediately address the potential respiratory compromise associated with hypokalemia-induced muscle weakness. Assessing respiratory status is more directly relevant to the observed change in handgrip strength.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Urine output is greater than 0.5 mL/kg/hr
During the fluid resuscitation phase of burn management, one of the primary goals is to maintain adequate tissue perfusion and organ function by ensuring sufficient fluid intake. The best method for assessing the results of fluid resuscitation is by monitoring urine output. A urine output of greater than 0.5 mL/kg/hr is indicative of adequate renal perfusion and kidney function, suggesting that fluid resuscitation is effective in maintaining tissue perfusion and preventing complications such as acute kidney injury.
B. Serum hemoglobin is 11 gm/dL
Serum hemoglobin levels can be affected by various factors, including fluid resuscitation, blood loss, and other medical conditions. While monitoring hemoglobin levels is important in overall patient assessment, it is not the best method specifically for assessing the results of fluid resuscitation during the initial phase of burn management.
C. Breath sounds are clear bilaterally
Clear bilateral breath sounds indicate adequate lung function and ventilation but may not directly reflect the effectiveness of fluid resuscitation in maintaining tissue perfusion. Lung sounds can be influenced by factors such as lung injury from smoke inhalation or mechanical ventilation settings, which may not correlate directly with fluid resuscitation outcomes.
D. Heart rate is 122/min
Heart rate can be influenced by various factors such as pain, stress, medications, and underlying medical conditions. While monitoring heart rate is important in assessing patient status, it is not the most reliable method for specifically evaluating the results of fluid resuscitation during the fluid resuscitation phase of burn management.
Correct Answer is D
Explanation
A. Provide a heart-healthy low-potassium diet:
While a heart-healthy low-potassium diet is essential for managing chronic hyperkalemia and preventing future occurrences, it is not the first intervention to implement in a patient with a serum potassium level of 7.5 mEq/L and exhibiting cardiovascular changes. The effects of dietary changes on serum potassium levels are gradual and may take days to have a significant impact. In an acute situation like this, immediate interventions are needed to rapidly lower potassium levels and address the associated cardiovascular risks.
B. Prepare to administer sodium polystyrene sulfate 15g by mouth:
Sodium polystyrene sulfate is a medication used to exchange sodium for potassium in the gastrointestinal tract, effectively lowering serum potassium levels over hours to days. While it is a valid treatment for hyperkalemia, its onset of action is not immediate enough to address the urgent cardiovascular changes seen in severe hyperkalemia. Therefore, it is not the first-line intervention in this scenario.
C. Prepare the patient for hemodialysis treatment:
Hemodialysis is an effective method for rapidly lowering serum potassium levels in cases of severe hyperkalemia. However, it is a more invasive and time-consuming procedure that requires preparation, including vascular access and dialysis setup. It is typically reserved for situations where other interventions have failed or in patients with severe or refractory hyperkalemia. In the context of this scenario, where the patient has a serum potassium level of 7.5 mEq/L and is exhibiting cardiovascular changes, hemodialysis may be considered if initial interventions are not successful, but it is not the first action to implement.
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