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. 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Wound tissue firm to palpation is a false expectation. While firmness can be an indicator of healing in some wounds, it's not a reliable indicator on its own. The appearance and characteristics of the tissue, including granulation tissue, are more significant indicators of healing.
Choice B reason:
Dry brown eschar is a false expectation. Brown eschar is often necrotic tissue that needs to be removed for the wound to heal. Its presence typically suggests a lack of healing progress.
Choice C reason:
Dark red granulation tissue is the correct expectation because it is a sign of healing in a pressure ulcer. Granulation tissue is the new tissue that forms during the healing process, and the dark red color indicates that the tissue is well-vascularized and receiving adequate blood supply, which is essential for healing.
Choice D reason:
Light yellow exudate is a false expectation. Light yellow exudate is often indicative of infection or non-healing wounds. While some exudate is normal in the healing process, its color alone doesn't necessarily indicate healing.
Correct Answer is B
Explanation
Choice A Reason:
Placing the client in a protective environment is not necessary for C. difficile gastroenteritis. Standard precautions, including diligent hand hygiene and appropriate personal protective equipment, are sufficient.
Choice B Reason:
Obtain a stool specimen with gloves is necessary. Obtaining a stool specimen with gloves is an appropriate nursing action when caring for a client with Clostridium difficile (C. difficile) gastroenteritis. C. difficile is a bacterium that can cause diarrhea and other gastrointestinal symptoms. It's important to follow infection control practices to prevent the spread of the bacteria.
Choice C Reason:
Cleaning surfaces with chlorhexidine is not the preferred disinfectant for C. difficile. Sporicidal agents, such as bleach-based solutions, are recommended to effectively kill the spores of C. difficile.
Choice D Reason:
Washing hands with alcohol-based hand rub is not sufficient for C. difficile. C. difficile spores are resistant to alcohol-based hand sanitizers, so using soap and water for handwashing is recommended to ensure proper removal of the spores.
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