A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Choice A reason:

Calling the lab to verify the client’s results is a reasonable step if there is any doubt about the accuracy of the lab results. However, in this scenario, the potassium level of 5.2 mEq/L is already documented, and the nurse should act on this information. Verifying the results would delay necessary actions and could potentially harm the patient if the high potassium level is not addressed promptly.

Choice B reason:

Omitting the KCL dose and documenting it as not given is a prudent action because administering potassium chloride to a patient with an elevated potassium level (5.2 mEq/L) could exacerbate hyperkalemia, which can lead to serious cardiac issues. However, this action alone is not sufficient. The nurse must also inform the prescribing physician to reassess the patient’s treatment plan.

Choice C reason:

Giving the ordered KCL as prescribed would be inappropriate in this situation. The patient’s potassium level is already elevated, and administering additional potassium could lead to hyperkalemia, which can cause dangerous cardiac arrhythmias or even cardiac arrest. Therefore, this option should be avoided.

Choice D reason:

Calling the prescribing physician and informing her of the client’s serum potassium level results is the most appropriate action. The physician needs to be aware of the elevated potassium level to make an informed decision about the patient’s treatment plan. The physician may decide to withhold the potassium chloride, order additional tests, or take other actions to manage the patient’s potassium levels safely.

Choice A reason: A client who had a stroke and is to be admitted

Assigning a client who had a stroke and is to be admitted might not be the best choice for an RN floated from the maternal-newborn unit. Stroke patients often require specialized neurological assessments and interventions that the RN might not be familiar with. Additionally, the initial admission process can be complex and time-consuming, requiring familiarity with the specific protocols and procedures of the medical-surgical unit.

Choice B reason: A client who is one-day postoperative following a total abdominal hysterectomy

This is the most appropriate assignment for the RN floated from the maternal-newborn unit. The RN is likely to be familiar with postoperative care, especially related to abdominal surgeries, given their experience in the maternal-newborn unit. Postoperative care involves monitoring vital signs, managing pain, and ensuring proper wound care, all of which are within the RN’s skill set. This familiarity can help ensure the client receives competent and safe care.

Choice C reason: A client who has acute pancreatitis

Acute pancreatitis can be a complex condition requiring specialized knowledge of gastrointestinal issues and potential complications such as fluid and electrolyte imbalances, respiratory issues, and severe pain management. The RN from the maternal-newborn unit may not have the specific expertise needed to manage these complexities effectively.

Choice D reason: A client who has terminal end-stage renal disease

Caring for a client with terminal end-stage renal disease involves managing complex chronic conditions, including fluid balance, electrolyte management, and possibly dialysis. This requires specialized knowledge and skills that the RN from the maternal-newborn unit might not possess. Additionally, end-of-life care requires a specific set of competencies and experience that might not be within the RN’s usual scope of practice.