The RN has completed an assessment on a client. What should the nurse do next?

Choice A reason: Utilize supine positioning to maximize chest expansion is not an important intervention for clients with a BMI greater than or equal to 30. Supine positioning is when the client lies flat on their back. This position can actually impair chest expansion and breathing for clients with a high BMI, as the weight of the abdomen and chest can compress the lungs and diaphragm. A semi-Fowler's position, where the head of the bed is elevated at 30 to 45 degrees, is preferred for these clients, as it reduces the pressure on the chest and improves ventilation.

Choice B reason: Use an appropriately sized blood pressure cuff is an important intervention for clients with a BMI greater than or equal to 30. A blood pressure cuff that is too small or too tight can cause inaccurate readings and increase the risk of injury to the client. A blood pressure cuff that is too large or too loose can also cause inaccurate readings and compromise the quality of care. A blood pressure cuff that fits the client's arm circumference and width is essential for obtaining accurate and reliable measurements and preventing complications.

Choice C reason: Consult a nutritionist because the client is malnourished/underweight is not an important intervention for clients with a BMI greater than or equal to 30. A BMI greater than or equal to 30 indicates that the client is obese, not malnourished or underweight. Obesity is a condition where the client has excess body fat that can affect their health and well-being. Malnutrition is a condition where the client has inadequate or imbalanced intake of nutrients that can affect their growth and development. Underweight is a condition where the client has a low body weight that can affect their immunity and energy. A nutritionist can help clients with any of these conditions, but the statement is incorrect for clients with a high BMI.

Choice D reason: Place the client on fall precautions because of increased risk for falls due to frail bones is not an important intervention for clients with a BMI greater than or equal to 30. Frail bones are not a common consequence of obesity, but rather of osteoporosis, a condition where the bones become weak and brittle. Obesity can actually increase the bone density and strength, as the bones have to support more weight. However, obesity can increase the risk for falls due to other factors, such as impaired mobility, balance, or coordination. Fall precautions are important for any client who is at risk for falls, but the statement is inaccurate for clients with a high BMI.

Choice A reason: This is the correct answer because stopping the KCl infusion is the first and most urgent action that the nurse should take. A high level of potassium in the blood, or hyperkalemia, can cause life-threatening cardiac arrhythmias and muscle weakness. The nurse should stop the source of excess potassium, which is the KCl infusion, and monitor the client's vital signs, electrocardiogram, and symptoms.

Choice B reason: This is not the correct answer because administering oral KCl is not the first or appropriate action that the nurse should take. Oral KCl would increase the potassium level in the blood, which is already too high. The nurse should avoid giving any potassium supplements or foods that are high in potassium, such as bananas, oranges, and potatoes.

Choice C reason: This is not the correct answer because encouraging fluids for dilution is not the first or effective action that the nurse should take. Fluids alone would not lower the potassium level in the blood, but rather dilute the concentration of other electrolytes, such as sodium and calcium. The nurse should administer fluids only as prescribed by the physician, and in conjunction with other treatments, such as diuretics, insulin, or sodium bicarbonate.

Choice D reason: This is not the correct answer because calling the pharmacy is not the first or priority action that the nurse should take. Calling the pharmacy may be necessary to obtain the medications that can lower the potassium level in the blood, such as diuretics, insulin, or sodium bicarbonate. However, the nurse should first stop the KCl infusion and notify the physician, who will order the appropriate medications and dosages.