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.
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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Related Questions
Correct Answer is B
Explanation
The statement "I had the stomach flu earlier this week and couldn't take the hydrocortisone" indicates that the patient may not be adhering to their prescribed medication regimen, which can lead to an Addisonian crisis. Therefore, the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge of management of the condition is appropriate.
Addison’s disease is a condition in which the adrenal glands do not produce enough cortisol and aldosterone. Hydrocortisone is a glucocorticoid medication that is often used to replace the cortisol that the adrenal glands are not producing. In the Addisonian crisis, the body is unable to produce the necessary levels of cortisol and aldosterone, which can lead to potentially life-threatening complications such as hypotension, dehydration, and electrolyte imbalances.
The other statements may indicate areas where patient education is needed, but they do not directly relate to the immediate risk of an Addisonian crisis.
Correct Answer is A
Explanation
Clients with acute gastritis are recommended to eat smaller, frequent meals instead of three large meals. This helps to reduce the workload on the digestive system and allows the stomach to heal. Therefore, option A is not a suitable nursing intervention for a client with acute gastritis.
Options b, c, and d are all appropriate nursing interventions for a client with acute gastritis. Observing stool characteristics can help to identify any bleeding or inflammation in the gastrointestinal tract, evaluating intake and output can help to identify any fluid imbalances, and monitoring laboratory reports of electrolytes can help to identify any imbalances that may occur because of vomiting or diarrhea.
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