A nurse is assisting with a presentation about caring for clients who are receiving diuretic therapy. The nurse should explain that which of the following medications can put clients at risk for hyperkalemia?

A. Insert the IV catheter:

Inserting an IV catheter is necessary to administer IV fluids and medications. However, it is not the most immediate need. The priority is to address the client's oxygenation status first to stabilize them before proceeding with other interventions.

B. Obtain a blood sample:

Obtaining a blood sample for cardiac enzyme levels is important to diagnose a myocardial infarction. Nevertheless, this step should be taken after ensuring the client is receiving adequate oxygen, as hypoxia needs to be addressed immediately.

C. Attach the leads for a 12-lead ECG:

Attaching the leads for a 12-lead ECG is crucial for diagnosing the client's cardiac condition. However, it should be done after initiating oxygen therapy, as improving the client's oxygenation status is more urgent and can help stabilize the client for further diagnostic procedures.

D. Initiate oxygen therapy:

Initiating oxygen therapy is the most critical first action. The client is experiencing severe chest pain, shortness of breath, and signs of cyanosis, indicating that their oxygen levels are insufficient. Providing oxygen at 4 L/min via nasal cannula will help alleviate hypoxia, improve the client's condition, and provide time for further diagnostic and therapeutic interventions.

(A) “I promise I won’t tell anyone about this.”: This statement is inappropriate because it is the nurse’s legal and ethical duty to report any suspicion or evidence of child abuse to the appropriate authorities. Keeping the information confidential could potentially endanger the child.

(B) “Let’s discuss what you have told me with your family members.”: This statement could potentially put the child at further risk, especially if the abuser is a family member. The child’s safety is the primary concern, and discussing the abuse with family members without the involvement of child protective services could be harmful.

(c) “Your family is bad for doing this to you.”: This statement is judgmental and unprofessional. It’s important to maintain a neutral stance and focus on the child’s feelings and safety rather than placing blame.

(D) “It is not your fault that this happened.”: This is the most appropriate response. It’s crucial to reassure the child that they are not to blame for the abuse. This can help alleviate feelings of guilt or shame that the child may be experiencing. The nurse should also take steps to ensure the child’s immediate safety and report the abuse to the appropriate authorities.