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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A Reason:
Repositioning the client's left arm is incorrect. Repositioning the arm might help prevent kinks or occlusions in the tubing, but addressing the tubing connections comes first.
Choice B Reason:
Checking the IV site for redness is incorrect. Checking for redness is important to assess for signs of infection or inflammation, but it can wait until after addressing the tubing issue.
Choice C Reason:
Ensuring the tubing connections are secure is correct. When the infusion pump alarms, the first step is to ensure that the tubing connections are secure. A loose or disconnected tubing can lead to interrupted or inadequate infusion, which could affect the client's treatment and well-being. By checking and securing the tubing connections, the nurse can address any immediate issues related to the alarm.
Choice D Reason:
Flushing the IV catheter is incorrect - Flushing the catheter might be necessary if there are blockages or if medications need to be administered, but addressing the tubing connections is the immediate priority when the infusion pump alarms.
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