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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason:

To prevent alveolar collapse is the correct answer. Positive end-expiratory pressure (PEEP) is used in mechanical ventilation to prevent alveolar collapse during expiration. Alveolar collapse, also known as atelectasis, can occur when the alveoli (air sacs in the lungs) collapse and don't fully re-inflate during the breathing cycle. This can lead to impaired gas exchange and decreased lung compliance. By applying positive pressure to the airways at the end of expiration, PEEP helps keep the alveoli open and improves oxygenation by maintaining lung volume.

Choice B Reason:

Positive airway pressure during inspiration is typically provided by the inspiratory pressure support, not by PEEP.

Choice C Reason:

Tidal volume refers to the amount of air moved into and out of the lungs with each breath. It is not the purpose of PEEP.

Choice D Reason:

Controlling the rate of ventilations is usually achieved by adjusting the ventilator settings for respiratory rate, not by using PEEP.

A. “use my heating pad on a low setting to keep my feet warm" B. ”rest in my recliner with my feet elevated for about an hour every afternoon” C. “soak my feet in hot water before trimming my toenails” D. “apply a lubricating lotion to the cracked areas on the soles of my feet every morning”

Correct Answer is D

Explanation

Choice A reason:

"use my heating pad on a low setting to keep my feet warm". This statement is incorrect. Using a heating pad, especially on a low setting, is not recommended for individuals with PAD. It can lead to burns or skin damage due to reduced sensation in the feet.

Choice B reason:

"rest in my recliner with my feet elevated for about an hour every afternoon" This statement is incorrect. While elevating the feet can help with blood circulation, it's important to avoid prolonged periods of inactivity. Regular physical activity is important for improving circulation.

Choice C reason:

"soak my feet in hot water before trimming my toenails". This statement is incorrect. Soaking feet in hot water can cause burns or damage to the skin for individuals with reduced sensation due to PAD. Trimming toenails should be done carefully and without soaking to prevent injury and infection.

Choice D reason:

"apply a lubricating lotion to the cracked areas on the soles of my feet every morning “This statement is correct. Clients with peripheral arterial disease (PAD) are at risk of reduced blood circulation to the extremities, including the feet. Proper foot care is crucial to prevent complications such as non-healing wounds or infections. Applying a lubricating lotion to cracked areas can help keep the skin moisturized and prevent further complications.

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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?

Nursing Test Bank

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Correct Answer is D

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