A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan?
Give a dose of alendronate.
Administer furosemide.
Apply a cardiac monitor.
Monitor for Chvostek's sign.
The Correct Answer is C
A. Give a dose of alendronate is incorrect. Alendronate is a medication used to treat osteoporosis, and it does not address low potassium levels. In this case, the focus should be on correcting the potassium imbalance.
B. Administer furosemide is incorrect. Furosemide is a diuretic that can cause further loss of potassium. In a client with low potassium levels (hypokalemia., administering furosemide could worsen the condition and lead to life-threatening complications.
C. Apply a cardiac monitor is correct. Hypokalemia (potassium level of 2.9 mEq/L) can cause significant cardiac arrhythmias, including ventricular tachycardia or fibrillation. Applying a cardiac monitor is essential for monitoring the client’s heart rhythm and detecting any abnormalities related to the low potassium level.
D. Monitor for Chvostek's sign is incorrect. Chvostek's sign is indicative of hypocalcemia, not hypokalemia. While both hypocalcemia and hypokalemia can cause neuromuscular excitability, monitoring for Chvostek’s sign is not a priority in the management of hypokalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "If I were you, I would contact your spiritual director.": While this may be a helpful suggestion for the client, it can come across as dismissive of the client’s personal beliefs and decision-making. The nurse should respect the client’s autonomy in making healthcare decisions.
B. "I'm sure that everything will be all right, regardless of your decision.": This statement may be dismissive of the client's concerns and the seriousness of their medical decision. It also minimizes the importance of the client’s decision, which should be respected.
C. "Making this decision is wrong.": This response is judgmental and violates the client’s autonomy. The nurse should avoid imposing personal beliefs and instead support the client’s choices.
D. "You have a right to change your mind.": This is the best response, as it acknowledges the client’s autonomy and the possibility that the client may reconsider their decision in the future. It provides a nonjudgmental and supportive statement that empowers the client.
Correct Answer is C
Explanation
A. "Wear sterile gloves when in contact with body fluids" is incorrect. While sterile gloves are necessary for sterile procedures, clean gloves are generally sufficient for contact with body fluids. The main focus of hand hygiene is on proper handwashing techniques.
B. "Use alcohol-based cleanser when hands are visibly soiled" is incorrect. Alcohol-based hand sanitizers should not be used when hands are visibly soiled, as they are less effective in removing dirt, grease, or organic material. Soap and water are needed for visibly soiled hands.
C. "Wash hands with soap and water for 20 seconds" is correct. The recommended duration for handwashing is 20 seconds, which is sufficient for removing pathogens effectively. This is standard practice for maintaining proper hand hygiene in healthcare settings.
D. "Artificial nails can be worn when performing direct client care" is incorrect. Artificial nails and chipped nail polish are contraindicated in healthcare settings because they can harbor bacteria and increase the risk of infection transmission.
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