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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Practice standards indicateblood should be infused through a 20-gauge or larger catheter to prevent hemolysis [destruction] of red blood cells. Y tubing with 0.9% sodium chloride is used to administer blood products is not necessary.A unit of packed RBCs should be administered over 2 to 4 hours, unless otherwise ordered by the provider, to reduce the risk of fluid overload and transfusion reactions . The client's vital signs should be obtained before, during (15 minutes after starting and every hour thereafter), and after the transfusion to monitor for any signs of adverse reactions.

A. "Most clients feel better after taking the antibiotic." B. "Your provider wouldn't prescribe this medication if it weren't necessary." C. "I will tell your provider that you do not want to take this medication." D. "If you don't take this medication, you will feel worse."

Correct Answer is C

Explanation

B. This response educates the client about the importance of taking the prescribed medication and reinforces the authority and expertise of the provider. However, it does not respect the client's autonomy to make independent healthcare decisions

C.This response acknowledges that the client has reservations about the antibiotics and offers to communicate this to the healthcare provider for further intervention.

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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

A nurse is preparing to administer a unit of packed RBCS to a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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