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:

Breast enlargement is not a known side effect of ginkgo biloba. This herbal supplement is primarily used for its potential benefits in improving cognitive function and circulation. There is no evidence to suggest that ginkgo biloba causes breast enlargement.

Choice B reason:

Decreased alertness is not typically associated with ginkgo biloba. In fact, ginkgo biloba is often taken to enhance cognitive function and alertness. It is believed to improve blood flow to the brain, which can help with memory and mental clarity.

Choice C reason:

Bad breath is not a common side effect of ginkgo biloba. While some herbal supplements can cause changes in breath odor, ginkgo biloba is not known to have this effect. Bad breath is more commonly associated with poor oral hygiene or certain foods.

Choice D reason:

Bleeding gums can be a side effect of ginkgo biloba. This supplement has blood-thinning properties, which can increase the risk of bleeding. People taking ginkgo biloba should be cautious if they are also taking other blood-thinning medications or have conditions that predispose them to bleeding.

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.