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:

Recommending staying at a local shelter might not be appropriate unless the client's health is in immediate danger due to the low temperature. It's better to explore other options first.

Choice B reason:

Contacting the client's family members about their financial status might not be necessary or respectful of the client's privacy without their consent.

Choice C reason:

Contact the local Department of Health and Human Services for the client. Contacting the local Department of Health and Human Services can help ensure that appropriate resources and assistance are provided to the client. They may have programs or services available to assist individuals who are struggling to afford heating during the winter. This action addresses the immediate concern of the client's health and the living environment.

Choice D reason:

Providing information about the dangers of hypothermia is important, but the client's current situation of living in a cold environment should be addressed first. The nurse can provide this information along with appropriate resources to help the client.

A. Loose tracheal secretions B. Hypoactive bowel sounds C. High-pitched sound on inspiration D. Client report of pain at the incision

Correct Answer is C

Explanation

Choice A reason:

Loose tracheal secretions are incorrect. While this could lead to airway issues if not managed, it's not as urgent as stridor.

Choice B reason:

Hypoactive bowel sounds are incorrect. Bowel sounds can be affected by anaesthesia and the surgical procedure, but they are not as immediately critical as airway issues.

Choice C reason:

High-pitched sound on inspiration. A high-pitched sound on inspiration, also known as stridor, can indicate a potential issue with the airway or breathing. Stridor can occur due to narrowing or obstruction of the upper airway, which can be particularly concerning after a thyroidectomy. It could suggest edema, bleeding, or damage to the laryngeal nerves, which are critical for vocal cord function and airway control. Stridor could potentially lead to airway compromise, making it a priority to report to the provider for immediate evaluation and intervention.

Choice D reason:

Client report of pain at the incision is incorrect. Pain management is important, but it's not an immediate threat to the client's airway or overall condition.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?

Correct Answer is C

Explanation

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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?

A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

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