A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?
Listen to the client's bowel sounds.
Initiate cardiac monitoring for the client.
Check the client's hand grasps.
Administer an IV potassium drip.
The Correct Answer is B
Choice A reason:
Listening to the client's bowel sounds should not be implemented. It is important for assessing the gastrointestinal status, but the priority in this situation is to address the potential cardiac complications of hypokalaemia.
Choice B reason:
Initiating cardiac monitoring for the client should be implemented. A serum potassium level of 2.8 mEq/L is significantly low (normal range is typically around 3.5-5.0 mEq/L). Low potassium levels, known as hypokalaemia, can lead to serious cardiac arrhythmias and other complications. Therefore, the nurse should prioritize cardiac monitoring to assess for any potential changes or abnormalities in the client's heart rhythm due to the low potassium levels.
Choice C reason:
Checking the client's hand grasps should not be implemented. It is a test for muscle strength and can be indicative of hypokalaemia, but initiating cardiac monitoring is more critical at this point.
Choice D reason:
Administering an IV potassium drip may be necessary, but initiating cardiac monitoring takes precedence as the first action to ensure the client's heart rhythm is stable before addressing the potassium imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Magnesium - While magnesium levels can affect cardiac function, hypomagnesemia is not a primary risk factor for digoxin toxicity.
Choice B Reason:
Potassium. An imbalance of potassium can increase the risk of digoxin toxicity. Hypokalaemia (low potassium levels) enhances the binding of digoxin to its target receptors in the heart, leading to an increased risk of digoxin toxicity. It's essential to monitor potassium levels in clients taking digoxin, as maintaining a stable potassium level helps prevent adverse effects associated with digoxin therapy.
Choice C Reason:
Phosphatase - Phosphate levels are not commonly associated with an increased risk of digoxin toxicity.
Choice D Reason:
Calcium - Calcium levels can affect cardiac function, but they are not a primary factor in the development of digoxin toxicity.
Correct Answer is B
Explanation
Choice A reason:
Checking the client's vital signs is not appropriate. Checking vital signs is important to assess the severity of the reaction and monitor the client's overall condition.
Choice B reason:
Stopping the infusion is appropriate. Stopping the infusion is crucial to prevent further administration of the blood product that might be causing the adverse reaction. Once the infusion is stopped, the nurse can assess the client's condition more thoroughly and determine the appropriate steps to take next.
Choice C reason:
Collecting a urine sample is not appropriate. While urine sample collection may be important to assess for hemolysis (breakdown of red blood cells), it's not the first action to take. Stopping the infusion and assessing the client's vital signs are more immediate priorities.
Choice D reason:
Administering oxygen to the client is not appropriate. Providing oxygen might be necessary if the client is experiencing respiratory distress, but it's not the first action to take. Stopping the infusion and assessing the situation before providing additional interventions.
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