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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While promptly removing urinary catheters can reduce the risk of catheter-associated urinary tract infections (CAUTIs), it addresses only one specific type of infection. It doesn't comprehensively address other common healthcare-associated infections (HAIs) like central line-associated bloodstream infections (CLABSIs), surgical site infections (SSIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections (CDI).
Education about infection control methods, however, encompasses a broader range of preventive measures that can be applied to various HAIs, making it a more effective strategy for overall infection prevention.
Choice C rationale:
Placing patients in appropriate isolation can prevent the spread of infections, but it's a reactive measure that's implemented after an infection has already occurred. It doesn't address the root causes of infections or prevent their occurrence in the first place.
Education about infection control methods, on the other hand, is a proactive approach that aims to prevent infections from happening in the first place by teaching staff about proper hygiene practices, aseptic techniques, and other infection prevention strategies.
Choice D rationale:
Monitoring hand hygiene practices is crucial for infection prevention, but it's only one aspect of a comprehensive infection control program. Education about infection control methods goes beyond hand hygiene and covers various other preventive measures, such as:
Proper use of personal protective equipment (PPE) Aseptic technique during invasive procedures
Proper cleaning and disinfection of equipment and surfaces Proper handling of patient waste
Recognition of signs and symptoms of infection Prompt reporting of potential outbreaks
Therefore, educating staff members about infection control methods is the most effective action the nursing manager can take to prevent infections in the hospital unit because it provides a comprehensive approach to infection prevention, addressing various aspects of HAI prevention and promoting a culture of safety among healthcare staff.
Correct Answer is D
Explanation
Rationale for Choice A: Ensuring the client is warm
While maintaining client warmth is important for comfort and to prevent hypothermia, it is not the immediate priority upon arrival in the postoperative unit. Thermoregulation can be addressed after more urgent assessments have been completed.
Rationale for Choice B: Participating in hand-off report
A thorough hand-off report is essential for continuity of care, but it does not take precedence over assessing the client's immediate physiological status. The nurse can gather information from the report while simultaneously performing essential assessments.
Rationale for Choice C: Checking the surgical dressings
Monitoring surgical dressings is a crucial aspect of postoperative care, but it does not take priority over assessing fluid and blood output. Excessive bleeding or fluid shifts can rapidly compromise the client's hemodynamic stability and require prompt intervention.
Rationale for Choice D: Assessing fluid and blood output
This is the priority action for several reasons:
Monitoring for Hemorrhage: Early detection of excessive bleeding is crucial to prevent hypovolemic shock, a life-threatening complication. Postoperative bleeding can occur internally or externally, and prompt assessment of fluid and blood output allows for timely interventions to control bleeding and maintain hemodynamic stability.
Assessing Fluid Balance: Maintaining fluid balance is essential for optimal organ function and electrolyte balance. Postoperative clients are at risk for fluid imbalances due to blood loss, fluid shifts, and the use of diuretics or IV fluids. Assessing fluid intake and output helps to identify and address fluid imbalances early.
Evaluating Renal Function: Urine output is a key indicator of renal function. Postoperative clients are at risk for acute kidney injury due to factors such as hypotension, blood loss, and nephrotoxic medications. Assessing urine output helps to detect early signs of kidney dysfunction and initiate appropriate interventions.
Guiding Fluid and Blood Product Replacement: The assessment of fluid and blood output provides essential information to guide the administration of fluids and blood products as needed. This ensures that the client's fluid status and oxygen-carrying capacity are maintained within safe parameters.
Therefore, assessing fluid and blood output takes priority as it allows the nurse to identify and address potential life- threatening complications promptly, as well as guide interventions to maintain fluid balance and organ function.
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