The RN receives a call from the lab that a client's potassium chloride (KCl) level is 6.6 (normal range is 3.5 to 5 mEq/L). What should the nurse do first?
Stop the KCl infusion
Administer oral KCl
Encourage fluids for dilution
Call the pharmacy
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: White rice is not a food that can cause diarrhea, as it is a bland and starchy food that can help bind the stool and reduce the frequency of bowel movements.
Choice B reason: Ripe bananas are not a food that can cause diarrhea, as they are rich in potassium, which can help replenish the electrolytes lost due to diarrhea. They also contain pectin, a soluble fiber that can help firm up the stool.
Choice C reason: Low-fiber cereal is not a food that can cause diarrhea, as it is easy to digest and does not irritate the intestinal lining. It can also provide some energy and nutrients for the body.
Choice D reason: Prunes are a food that can cause diarrhea, as they are high in sorbitol, a sugar alcohol that can have a laxative effect and draw water into the colon. They also contain insoluble fiber, which can increase the bulk and speed of the stool.
Correct Answer is C
Explanation
Choice A reason: This is not the correct answer because reassessing the patient is not the next step after completing an assessment. Reassessment is done periodically or when there is a change in the patient's condition, but not immediately after the initial assessment.
Choice B reason: This is not the correct answer because writing nursing interventions is not the next step after completing an assessment. Nursing interventions are the actions that the nurse plans and implements to achieve the desired outcomes for the patient. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
Choice C reason: This is the correct answer because analyzing cues is the next step after completing an assessment. Analysis is the process of identifying patterns, relationships, and trends in the assessment data, and comparing them with the normal and expected findings. Analysis helps the nurse to identify the patient's problems, needs, strengths, and risks.
Choice D reason: This is not the correct answer because creating SMART goals is not the next step after completing an assessment. SMART goals are the specific, measurable, achievable, realistic, and time-bound outcomes that the nurse and the patient agree on. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
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