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?
Administer an IV potassium drip.
Listen to the client's bowel sounds.
Check the client's hand grasps.
Initiate cardiac monitoring for the client.
The Correct Answer is D
The client has hypokalemia, which is a low level of potassium in the blood. Hypokalemia can cause cardiac arrhythmias, which can be life-threatening. The nurse should initiate cardiac monitoring first to assess the client's heart rhythm and rate, and intervene if any abnormalities are detected. Administering an IV potassium drip is an appropriate intervention for hypokalemia, but it is not the first priority. Listening to the client's bowel sounds and checking the client's hand grasps are also relevant assessments for hypokalemia, as it can cause decreased bowel motility and muscle weakness, but they are not as urgent as cardiac monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is a low hemoglobin level, which may indicate blood loss. The nurse should report this finding to the provider immediately, as it may require further investigation and intervention, such as blood transfusion.
Correct Answer is B
Explanation
A complete AV block (also called third-degree AV block) is a type of heart block in which there is no electrical communication between the atria and ventricles. This means that the atria and ventricles beat independently of each other, resulting in a slow and irregular pulse. A complete AV block can cause symptoms such as dizziness, fainting, chest pain, shortness of breath, and heart failure.
A permanent pacemaker is a device that sends electrical impulses to the heart to regulate its rhythm and prevent bradycardia (slow heart rate). A permanent pacemaker is indicated for clients with complete AV block and rates slower than 40/min or symptomatic bradycardia.
The other options are not indications for a permanent pacemaker. Vasovagal bradycardia is a temporary drop in heart rate and blood pressure caused by a stimulus that triggers the vagus nerve, such as pain, stress, or straining.
It usually resolves on its own or with simple measures, such as lying down or elevating the legs. Sinus tachycardia is a normal increase in heart rate in response to physical or emotional stress, such as exercise, fever, or anxiety. It usually does not require treatment unless it is caused by an underlying condition or causes symptoms.
Asymptomatic second-degree AV block is a type of heart block in which some of the electrical impulses from the atria are blocked from reaching the ventricles. It may not cause any symptoms or affect the overall heart rate. It may be benign or transient, or it may progress to a more serious type of heart block. It may require monitoring or medication, but not a permanent pacemaker unless it causes symptomatic bradycardia.
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