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:

Peripheral pulses 2+ bilaterally - This indicates good peripheral circulation and is not typically a concerning finding.

Choice B Reason:

Creatinine 0.8 mg/dL - A creatinine level of 0.8 mg/dL is within the normal range and does not indicate acute kidney failure.

Choice C Reason:

Urine specific gravity 1.045 A urine specific gravity of 1.045 is significantly elevated and could indicate concentrated urine, which might be a concern in a client with acute kidney failure. Elevated specific gravity could suggest dehydration, impaired kidney function, or other kidney-related issues. The nurse should report this finding to the provider for further evaluation and intervention.

Choice D Reason:

Weight gain 1.1 kg (2.4 lb) in 24 hr - While weight gain should be monitored closely in clients with kidney failure, 1.1 kg in 24 hours might not be an immediate concern, depending on the client's overall condition and baseline weight. However, it should still be followed up on in subsequent assessments.

A. Carvedilol B. Clopidogrel C. Metformin D. Furosemide

Correct Answer is C

Explanation

Choice A Reason:

Carvedilol is not the correct medication. Carvedilol is a beta-blocker used for heart conditions, and there is no specific need to withhold it following a CT scan with contrast media.

Choice B Reason:

Clopidogrel is not the correct medication. Clopidogrel is an antiplatelet medication, and there is no specific need to withhold it following a CT scan with contrast media.

Choice C Reason:

Metformin is the correct medication. The nurse should instruct the client to withhold metformin for 48 hours following a CT scan with contrast media. Contrast media used in imaging procedures can potentially cause kidney damage, and when combined with metformin, there is a risk of a serious condition called lactic acidosis. Withholding metformin for 48 hours after the procedure helps prevent this risk.

Choice D Reason:

Furosemide is not the correct medication. - Furosemide is a diuretic, and there is no specific need to withhold it following a CT scan with contrast media.

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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 C

Explanation

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Correct Answer is C

Explanation

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