A nurse is providing teaching to the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include?

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:

The statement “Reposition the client a second time before assessing his respirations” is not appropriate in this scenario. If the client remains apneic after the initial airway repositioning, further repositioning is unlikely to be effective. Immediate action is required to determine the next steps in care.

Choice B reason:

The statement “Place a red tag on the client’s upper body and obtain immediate help from other personnel” is incorrect. A red tag is used for patients who require immediate medical attention and have a chance of survival with timely intervention. Since the client remains apneic despite airway repositioning, they are unlikely to survive without immediate advanced medical intervention, which may not be feasible in a mass casualty situation.

Choice C reason:

The statement “Place a black tag on the client’s upper body and attempt to help the next client in need” is correct. In a mass casualty incident, a black tag is used to indicate that a patient is deceased or expected to die due to the severity of their injuries and the lack of available resources to provide the necessary care. Since the client remains apneic with a weak pulse, they are unlikely to survive, and resources should be directed to those with a higher chance of survival.

Choice D reason:

The statement “Start CPR” is not the most appropriate action in this scenario. In a mass casualty situation, resources must be allocated to those who have the best chance of survival. Starting CPR on a client who remains apneic despite airway repositioning may not be the best use of limited resources, especially when other clients may need immediate attention and have a higher chance of survival.