In reviewing the electrolytes of a patient, the nurse notes the serum potassium level has increased from 4.3 mEq/L to 5.9 mEq/L. Which assessment does the nurse initiate first to prevent further harm?

Oxygen Stats

Pulse rate and Rhythm

Respiratory rate and depth

Deep tendon reflexes

Answer and Explanation

The Correct Answer is B

An increased serum potassium level, also known as hyperkalemia, can have adverse effects on the electrical conduction of the heart, potentially leading to life-threatening cardiac dysrhythmias. Therefore, it is crucial to assess the patient's pulse rate and rhythm promptly to identify any abnormal cardiac activity.

Assessing the oxygen saturation (oxygen stats), respiratory rate and depth, and deep tendon reflexes are also important assessments, but they are not the priority in this case. Hyperkalemia primarily affects cardiac function, and prompt identification of any potential cardiac rhythm disturbances is essential to prevent further harm.

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Correct Answer is C

Explanation

A low-pressure ventilator alarm indicates a potential issue with the delivery of adequate air or pressure from the ventilator. The pulse oximetry reading of 85% suggests that the client is not receiving sufficient oxygenation.

Providing ventilation with a bag-valve-mask device allows the nurse to manually assist the client's breathing and ensure proper oxygenation and ventilation while troubleshooting the ventilator alarm. By manually ventilating the client, the nurse can help maintain oxygenation and prevent further hypoxemia until the underlying cause of the alarm can be identified and resolved.

Suctioning the client's endotracheal tube, adding air to the pilot balloon, or placing a bit block in the client's mouth may be appropriate interventions in specific situations, but they are not the immediate priority in this case. The primary concern is to address the low oxygen saturation and ensure adequate ventilation.

A. administration of antiemetics B. administration of diuretics C. Possible Electrolyte replacement if warranted D. Administration of IV 0.9 Saline Solution infusion E. Have the patient go home and rest. It will resolve itself shortly.

Correct Answer is D

Explanation

Mrs. Kalen is diagnosed with gastroenteritis and dehydration, and the arterial blood gas results indicate metabolic alkalosis (elevated pH and HCO3-). This suggests that there is an excessive loss of gastric acid and chloride ions from vomiting, leading to an imbalance of electrolytes and an increase in bicarbonate levels.

To correct the imbalance and treat dehydration, the primary intervention is fluid replacement. Administration of IV 0.9 Saline Solution, also known as normal saline, is commonly used for fluid resuscitation and rehydration. This isotonic solution helps restore fluid balance and electrolyte levels in the body.

Administration of antiemetics may help control vomiting, but the primary treatment focus in this case is fluid and electrolyte replacement to correct dehydration and the associated metabolic alkalosis.

Administration of diuretics, which increase urine output, would not be appropriate in this case as the patient is already experiencing dehydration.

Electrolyte replacement may be necessary if there are specific electrolyte imbalances identified, but the primary treatment is fluid replacement with IV saline solution.

Having the patient go home and rest without addressing the underlying dehydration and metabolic alkalosis would not be appropriate as it can lead to further complications.

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In reviewing the electrolytes of a patient, the nurse notes the serum potassium level has increased from 4.3 mEq/L to 5.9 mEq/L. Which assessment does the nurse initiate first to prevent further harm?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client on a ventilator from complications of pneumonia. The nurse observes the low-pressure ventilator alarm and a pulse oximetry reading of 85%. What should be the nurse's first action?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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