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 A
Explanation
The nurse should instruct the client to use a 10-mL syringe or larger to flush the PICC line with normal saline or heparin solution, as prescribed, to prevent occlusion and thrombosis. The other options are incorrect because they may cause complications such as infection, phlebitis, or bleeding.
Correct Answer is A
Explanation
A halo device is a type of external fixation device that immobilizes the cervical spine after an injury or surgery. The device consists of a metal ring attached to four metal rods that are secured to a vest worn by the client. The device limits the movement of the head and neck, which can impair the client's ability to drive safely. The nurse should clarify with the provider if the client can operate a motor vehicle while wearing the halo device, as this may pose a risk for injury to the client and others on the road.
Placing a small pillow under the head when sleeping, increasing intake of fiber-rich foods, and taking tub baths instead of showers are all appropriate instructions for a client with a halo device
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