A nurse is completing the 8-hr 1&0 record for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth.

The client also received 300 mL of 0.9% sodium chloride IV. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number.)mL.

Choice A rationale:

Repeating the potassium level is not the first action to take. The nurse already has a recent lab value.

Choice B rationale:

The nurse should withhold the medication. The normal range for potassium is 3.5-5.0 mEq/L. A level of 5.5 mEq/L is high, so giving more potassium could lead to hyperkalemia.

Choice C rationale:

Monitoring for paresthesia is important in hyperkalemia, but it is not the first action. The nurse should first prevent further increase in potassium levels.

Choice D rationale:

Administering a hypertonic solution is not relevant in this situation. It does not directly address the high potassium level.

Choice A rationale:

While calling 911 is important, it is not the first action the nurse should take. The nurse should first assess the victim’s condition.

Choice B rationale:

The first action when someone is choking is to ask if they can speak. If they can speak, it means air is still passing through the windpipe.

Choice C rationale:

The jaw-thrust maneuver is used to open the airway in an unconscious victim, not in a choking victim.

Choice D rationale:

Abdominal thrusts (Heimlich maneuver) are used when the victim cannot speak, indicating a complete airway obstruction.