A nurse is preparing to administer oral potassium to a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?

Withhold the medication.

Administer a hypertonic solution.

Repeat the potassium level.

Monitor for paresthesia.

Answer and Explanation

The Correct Answer is C

Before administering any medication, the nurse should confirm the potassium level to ensure that it is still elevated and needs to be treated. Potassium levels can ﬂuctuate, so repeating the test will ensure that the client receives the appropriate treatment.

Options (a) Withhold the medication and (b) Administering a hypertonic solution may be appropriate interventions depending on the client's condition, but confirming the potassium level is the first step.

Option (d) Monitoring for paresthesia is important but not the first action that the nurse should take.

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Correct Answer is C

Explanation

Clostridium difficile is a highly contagious bacteria that can spread easily from person to person. The patient should be placed in a private room to prevent the spread of the infection to other patients. Contact isolation precautions should also be implemented, which involves wearing gloves and a gown when entering the patient's room, as well as washing hands thoroughly after leaving the room.

Options a and b are not directly related to the care of a patient with Clostridium difficile. Option d is also not directly related, although proper food handling and storage can help prevent the spread of other types of infections.

A. encourage the patient to drink at least 3000 ml of ﬂuid a day. B. suggest that the patient increase dietary intake of foods that are high in fiber. C. inform the patient that a daily bowel movement is not necessary. D. perform a focused nursing assessment to identify risk factors for constipation.

Correct Answer is D

Explanation

Although increasing ﬂuid intake and fiber intake are important interventions for preventing constipation, it is important to first assess the patient's current situation and risk factors for constipation. Additionally, while a daily bowel movement is not necessary for everyone, it is important to understand the patient's usual bowel habits and whether or not their current regimen is eﬀective for them. Therefore, the nurse should perform a focused nursing assessment to identify the patient's risk factors for constipation and evaluate their current bowel regimen before providing specific interventions or recommendations.

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A nurse is preparing to administer oral potassium to a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?

Nursing Test Bank

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