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. While assessing bowel sounds is important, it is not the highest priority in this situation. The client's low serum potassium level indicates the potential for serious cardiac arrhythmias, so actions related to monitoring and addressing this electrolyte imbalance are more critical.

Choice B reason:

Initiate cardiac monitoring for the client is the correct answer. A serum potassium level of 2.8 mEq/L is significantly low and can lead to life-threatening cardiac arrhythmias. Initiating cardiac monitoring is crucial to assess the client's heart rhythm and ensure that any potential abnormalities are identified promptly.

Choice C reason:

Check the client's hand grasps should not be implemented. Assessing the client's hand grasps can provide information about muscle strength, but it is not the immediate priority when the client has a critically low potassium level.

Choice D reason:

Administer an IV potassium drip should not be implemented. Administering IV potassium is important for correcting the potassium imbalance, but the priority is to assess and monitor the client's cardiac status first. Rapid administration of potassium can lead to cardiac arrhythmias, so it's important to ensure the heart's stability through cardiac monitoring before administering potassium.

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Correct Answer is C

Explanation

Choice A Reason:

Administering the unit of packed RBCs over 1 hour is not appropriate. Packed RBCs are usually administered over a longer period of time (typically 2 to 4 hours), as rapid infusion can lead to adverse reactions. The rate of administration should be based on institutional policy.

Choice B Reason:

Initiating venous access with a 21-gauge needle is not appropriate-. The needle size for venous access can vary based on the client's condition and the size of their veins. However, a larger gauge needle (e.g., 18-gauge or 20-gauge) is typically used for blood transfusions to ensure adequate flow.

Choice C Reason:

Blood products should be infused through administration sets designed specifcally for blood; use a Y-tubing or straight-tubing blood administration set that contains a filter designed to trap fibrin clots and other debris that accumulate during blood storage.

Choice D Reason:

The nurse should measure vital signs and assess lung sounds before the transfusion and again after the first 15 minutes and every 30 minutes to 1 hour (per agency policy) until 1 hour after the transfusion is completed.

A. COPD B. Thalassemia C. Thrombocytopenia D. Rheumatoid arthritis

Correct Answer is C

Explanation

Choice A Reason:

COPD (Chronic Obstructive Pulmonary Disease) - While COPD might influence the choice of anaesthesia and perioperative management, it is not a direct contraindication to heparin.

Choice B Reason:

Thalassemia - Thalassemia is a genetic blood disorder that affects haemoglobin production and the structure of red blood cells. It does not directly impact the ability to receive heparin.

Choice C Reason:

Thrombocytopenia. Thrombocytopenia, which is a low platelet count, is a contraindication to receiving heparin, an anticoagulant. Heparin works by preventing the formation of blood clots, but if a person has a low platelet count, their ability to form blood clots is already compromised. Administering heparin in this situation could increase the risk of bleeding and further reduce platelet count.

Choice D Reason:

Rheumatoid arthritis - Rheumatoid arthritis is an autoimmune condition affecting joints. It is not a contraindication to heparin use, but the client's overall health and medications should be considered when planning surgery and anticoagulant therapy.

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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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A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take?

Correct Answer is C

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Correct Answer is C

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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?

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