A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of the following information should the nurse include in the discharge instructions? (Select all that apply)

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: Client reports knee pain changed from 4/10 to 6/10 is an important finding, but it is not as critical as a significant drop in blood pressure. Pain levels can fluctuate postoperatively, and while increased pain should be addressed, it does not typically require immediate notification of the provider unless it is severe or unmanageable.

Choice B reason: Pulse oximetry changed from 98% to 96% is a minor change and still within normal limits. A pulse oximetry reading of 96% is generally acceptable and does not indicate a critical issue that requires immediate provider notification.

Choice C reason: Temperature changed from 37.2°C (99.0°F) to 37.5°C (99.5°F) is a slight increase and still within the normal range. Postoperative patients can experience minor fluctuations in temperature, and this change does not typically indicate a serious problem.

Choice D reason: Systolic blood pressure changed from 140 mm Hg to 110 mm Hg is a significant drop and could indicate hypotension, which can be a serious complication, especially in an older adult post-surgery. Hypotension can result from various causes, including blood loss, dehydration, or effects of anesthesia, and requires prompt assessment and intervention.