The nurse is reviewing a client’s laboratory results and notes the serum potassium level is 2.8 mEq/L. Which nursing action should be initiated immediately?

Institute hourly neurologic checks.

Initiate cardiac monitoring.

Initiate seizure precautions.

Administer oxygen via face mask.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Hourly neurologic checks are not the priority intervention for a client with hypokalemia. While hypokalemia can cause neuromuscular changes, such as muscle weakness and cramps, these are not typically the most immediate or life-threatening concerns.
Cardiac monitoring is crucial to detect and manage potentially fatal arrhythmias promptly.

Neurologic checks can be implemented as part of the overall assessment and monitoring plan, but they should not supersede cardiac monitoring in this situation.
Choice C rationale:
Seizure precautions are not routinely initiated for clients with hypokalemia unless there is a specific seizure history or other neurological concerns.
Hypokalemia can cause neuromuscular irritability, but it does not directly trigger seizures in most cases. The priority remains cardiac monitoring due to the significant risk of arrhythmias.
Choice D rationale:
Administering oxygen via face mask might be considered if the client exhibits respiratory distress or hypoxemia. However, it's not the immediate priority intervention for hypokalemia without accompanying respiratory compromise.
Hypokalemia primarily affects cardiac conduction, necessitating prompt cardiac monitoring.
Oxygen therapy can be administered if clinically indicated, but it does not address the underlying electrolyte imbalance.
Rationale for the correct answer, B:
Initiating cardiac monitoring is the most crucial nursing action for a client with a serum potassium level of 2.8 mEq/L. Here's a detailed explanation:
Hypokalemia's significant cardiac effects:
Potassium is essential for normal cardiac conduction and muscle contraction. Hypokalemia disrupts the electrical activity of the heart, potentially leading to:
Arrhythmias (irregular heartbeats), including potentially fatal ones like ventricular tachycardia or fibrillation. Electrocardiogram (ECG) changes, such as ST segment depression, T wave flattening or inversion, and prominent U waves. Cardiac monitoring's role:
Continuously tracks the heart's electrical activity. Enables early detection of arrhythmias.
Facilitates prompt intervention to prevent life-threatening complications. Specific benefits of cardiac monitoring in hypokalemia:

Allows for early identification and treatment of arrhythmias, potentially preventing cardiac arrest. Guides electrolyte replacement therapy, ensuring appropriate potassium administration.
Assesses the effectiveness of interventions, ensuring the patient's stability.

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Correct Answer is B

Explanation

Choice A rationale:
Massaging the site with scented oils is not recommended for pain relief after removal of a peripheral vascular access device. There is no evidence to support the effectiveness of scented oils in this context.
Additionally, some scented oils can be irritating to the skin, which could potentially worsen the pain, redness, and swelling.
It's crucial to use products that are specifically designed for wound care and pain management, and to follow the healthcare provider's instructions.
Choice B rationale:
Applying warm compresses to the site is an effective and recommended intervention to alleviate pain, redness, and swelling after removal of a peripheral vascular access device.
Warm compresses have the following beneficial effects:
Vasodilation: They promote blood flow to the area, which helps to reduce inflammation and pain. Muscle relaxation: The warmth helps to relax tense muscles, further easing discomfort.
Pain relief: Warmth can directly inhibit pain signals, providing a soothing sensation.
Increased circulation: Improved blood flow can help to remove inflammatory substances and promote healing. It's important to use a clean, warm compress and to apply it for 15-20 minutes at a time, several times a day.
Choice C rationale:
Topical lidocaine is a local anesthetic that can temporarily numb the skin.
While it can be used for pain relief, it's not typically the first-line intervention for pain associated with removal of a peripheral vascular access device.
Warm compresses are often preferred as they provide a more natural and non-invasive approach to pain management.
Choice D rationale:
Oral pain medication may be necessary if warm compresses do not provide adequate pain relief.
However, it's important to follow the healthcare provider's instructions regarding the type and dosage of pain medication to use.
Over-the-counter pain relievers, such as acetaminophen or ibuprofen, may be sufficient in some cases. Stronger prescription pain medication may be needed for more severe pain.

A. Demonstrate to the family how to avoid spreading the disease. B. Reassure the family that they will not get the infection. C. Encourage the family that it is important that they visit the client. D. Inform them that these precautions are mandated by law.

Correct Answer is A

Explanation

Choice A rationale:
Addresses the family's fear directly: By demonstrating how to avoid spreading the disease, the nurse directly addresses the family's primary concern, which is the fear of contracting the infection. This proactive approach provides education and reassurance, empowering the family to make informed decisions about visitation.
Promotes understanding and adherence to precautions: Clear instruction on how to don and doff personal protective equipment, hand hygiene techniques, and other infection control measures increases the likelihood that the family will follow the precautions correctly, reducing the risk of transmission.
Empowers the family to make informed choices: By providing knowledge and skills, the nurse enables the family to feel more confident in their ability to visit safely. This sense of control can help to alleviate anxiety and promote positive coping mechanisms.
Facilitates open communication and trust: The demonstration creates an opportunity for the nurse to answer questions, address concerns, and build rapport with the family. This open dialogue can foster trust and collaboration, which are essential for effective care.
Choice B rationale:
May provide false reassurance: While it's important to offer support and hope, it's not always possible to guarantee that family members will not contract the infection. Absolute reassurances could potentially lead to complacency or disregard for precautions, increasing the risk of transmission.
Fails to address the need for education: Simply stating that the family won't get sick doesn't provide them with the knowledge and skills needed to protect themselves and the client. This lack of understanding could result in accidental transmission.
Choice C rationale:
May pressure the family: Encouraging visitation without addressing underlying fears and concerns could be perceived as pressure, leading to resentment, anxiety, or even avoidance. It's important to respect the family's decision-making process and provide support regardless of their choice.
Doesn't prioritize safety: While emotional support is important, the primary focus should be on ensuring the safety of both the client and the family. Encouraging visitation without proper education and precautions could compromise safety.
Choice D rationale:
Focuses on compliance rather than understanding: Informing the family about legal mandates may come across as authoritarian and could potentially increase anxiety or resistance. It's more effective to focus on the rationale behind the precautions and emphasize their role in protecting both the client and the family.

Misses an opportunity to build trust: Simply stating the rules without engaging in dialogue may hinder open communication and trust-building. Taking a collaborative approach and addressing concerns can lead to better understanding and adherence to precautions.

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The nurse is reviewing a client’s laboratory results and notes the serum potassium level is 2.8 mEq/L. Which nursing action should be initiated immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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