A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?

Correct answer: D

A.Metabolic acidosis occurs due to either increased production of metabolic acids, such as lactic acid in anaerobic metabolism, or decreased excretion of acids, such as in renal failure.Shallow respirations would not directly cause metabolic acidosis. While they may decrease the elimination of CO2, resulting in respiratory acidosis, they do not directly affect metabolic acid-base balance.

B.Respiratory alkalosis occurs when there is excessive elimination of CO2 from the body, leading to decreased levels of carbonic acid (H2CO3) in the blood. Shallow respirations would not typically lead to excessive elimination of CO2; instead, they would likely result in CO2 retention, leading to respiratory acidosis rather than respiratory alkalosis.

C.Metabolic alkalosis occurs due to excessive loss of acids or increased levels of bicarbonate (HCO3-) in the blood, often caused by conditions such as vomiting, excessive diuretic use, or excessive bicarbonate intake.Shallow respirations would not directly cause metabolic alkalosis. Again, while they may decrease CO2 elimination and lead to respiratory acidosis, they do not directly affect metabolic acid-base balance.

D.Respiratory acidosis occurs when the lungs cannot remove enough of the carbon dioxide (CO2) produced by the body. Shallow respirations lead to inadequate elimination of CO2, causing it to accumulate in the bloodstream. This accumulation of CO2 results in an increase in carbonic acid (H2CO3) in the blood, leading to a decrease in blood pH and resulting in respiratory acidosis.

Therefore, the nurse should identify the client as being at risk for developing respiratory acidosis initially due to the shallow respirations of 9/min.

A.While an assistive personnel (AP) might assist with some tasks, they are not typically responsible for providing detailed procedural guidance on medical tasks. The nurse should seek guidance from established protocols and trained professionals.

B.While online resources can be helpful, they might not reflect the specific protocols or best practices of the facility. It's crucial to follow the facility’s policies and procedures to ensure consistency and compliance with organizational standards.

C.While reviewing current literature is beneficial for understanding best practices, the most immediate and relevant source of information is the facility's own policies and procedures. These documents will reflect the specific protocols that the facility requires.

D.Reviewing the facility's policies and procedures manual ensures that the nurse follows the specific guidelines and standards set by the institution. This approach aligns with organizational requirements and helps ensure that the procedure is performed correctly and safely within the context of the facility’s protocols.