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 A

Explanation

Choice A Reason:

"I can drink vegetable juice with a meal."

Limiting sodium intake is a crucial part of managing heart failure, as excess sodium can lead to fluid retention and exacerbation of symptoms. Among the options provided, drinking vegetable juice with a meal is the one that suggests the client understands the need to limit sodium intake. Fresh vegetable juice typically has lower sodium content compared to other options, and incorporating it into meals can help the client manage their sodium intake.

Choice B Reason:

"I can have mayonnaise on my sandwiches." - Mayonnaise is often high in sodium and is not typically recommended in a low-sodium diet.

Choice C Reason:

"I can season my foods with garlic and onion salts." - Garlic and onion salts are often high in sodium. It's better to use fresh herbs and spices for seasoning.

Choice D Reason:

"I can have a frozen fruit juice bar for dessert." - Frozen fruit juice bars might contain added sugars or high sodium content. It's important to check the nutrition label for sodium content before consuming such items.

A. Diplopia B. Hyperproteinemia C. Cachexia D. Hypermagnesemia

Correct Answer is C

Explanation

Choice A Reason:

Diplopia is incorrect. Diplopia is double vision and is not a specific sign of malnutrition.

Choice B Reason:

Hyperproteinemia is incorrect - Malnutrition often leads to hypoalbuminemia (low levels of albumin, a protein), not hyperproteinemia.

Choice C Reason:

Cachexia is correct. Cachexia refers to a state of severe malnutrition and muscle wasting that can occur in individuals with chronic illnesses, especially advanced cancer, heart failure, or certain inflammatory conditions. It is characterized by significant weight loss, muscle atrophy, weakness, and fatigue. Cachexia goes beyond simple malnutrition and is a more severe manifestation of nutritional deficiency.

Choice D Reason:

Hypermagnesemia is incorrect - Malnutrition is more likely to cause deficiencies in minerals like magnesium, not excess levels (hypermagnesemia).

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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