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 A
Explanation
Choice A reason: This is the correct answer because the RN as a teacher aims to promote health literacy, self-management, and shared decision-making among patients and their families. By helping people to become empowered to take care of their health, the RN can facilitate positive health outcomes and prevent complications.
Choice B reason: This is not the correct answer because the RN as a teacher does not focus on explaining what nurses do, but rather on educating patients about their health conditions, treatments, and self-care. While it is important for the patient to understand the role of the nurse, this is not the main goal of teaching.
Choice C reason: This is not the correct answer because the RN as a teacher does not limit teaching to discharge instructions. Teaching is an ongoing process that starts from admission and continues throughout the continuum of care. Discharge instructions are only one component of teaching that summarizes the key information and actions that the patient needs to follow after leaving the hospital.
Choice D reason: This is not the correct answer because the RN as a teacher does not aim to teach patients how to give themselves treatments to get them out of the hospital quicker, but rather to help them achieve optimal health and wellness. Teaching patients how to give themselves treatments is part of the skill development aspect of teaching, but it is not the main goal. The main goal is to help patients understand the rationale, benefits, and risks of their treatments, and to support them in adhering to their treatment plans.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because safety is the second level of Maslow's hierarchy of needs, and it includes the needs for security, stability, protection, and freedom from fear and anxiety. The couple who just lost their house in a fire are likely experiencing a threat to their safety needs, as they have lost their shelter, possessions, and sense of security. The nurse should identify and address their safety needs as a priority, and help them find alternative housing, financial assistance, and emotional support.
Choice B reason: This is not the correct answer because self-actualization is the highest level of Maslow's hierarchy of needs, and it includes the needs for personal growth, fulfillment, and realization of one's potential. The couple who just lost their house in a fire are unlikely to be concerned with their self-actualization needs at this time, as they have more pressing and basic needs to meet. The nurse should focus on their lower-level needs first, before helping them achieve their higher-level needs.
Choice C reason: This is not the correct answer because esteem is the fourth level of Maslow's hierarchy of needs, and it includes the needs for self-respect, confidence, recognition, and appreciation. The couple who just lost their house in a fire may experience a loss of esteem, as they may feel ashamed, helpless, or worthless. However, their esteem needs are not the most urgent or important at this time, as they have more fundamental needs to satisfy. The nurse should support their esteem needs by showing empathy, respect, and encouragement, but not neglect their lower-level needs.
Choice D reason: This is not the correct answer because love and belonging is the third level of Maslow's hierarchy of needs, and it includes the needs for affection, intimacy, friendship, and social acceptance. The couple who just lost their house in a fire may benefit from their love and belonging needs, as they may seek comfort, support, and connection from others. However, their love and belonging needs are not the primary or essential at this time, as they have more basic and vital needs to fulfill. The nurse should facilitate their love and belonging needs by providing a caring and compassionate environment, but not overlook their lower-level needs.
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