When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?

Reference Range:
Potassium (K+) 3.5 to 5 mEq/L (3.5 to 5 mmol/L)

Observe color and amount of urine.

Determine apical pulse rate and rhythm.

Compare muscle strength bilaterally.

Assess strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is B

Choice A reason: Observing the color and amount of urine is important for assessing kidney function and hydration status but is not the most critical intervention for hypokalemia, which can have immediate life-threatening cardiac effects.

Choice B reason: Determining the apical pulse rate and rhythm is the most important intervention. Hypokalemia can lead to serious cardiac arrhythmias, and the apical pulse is the most accurate non-invasive way to assess cardiac rhythm and rate.

Choice C reason: Comparing muscle strength bilaterally is important for assessing the impact of hypokalemia on muscle function, but it is not as immediately life-threatening as cardiac effects.

Choice D reason: Assessing the strength of deep tendon reflexes can help evaluate neuromuscular involvement in hypokalemia but is less critical than monitoring for cardiac arrhythmias.

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Correct Answer is B

Explanation

Choice A reason: While fitting for an N95 mask is important, it is not required for droplet precautions, which are appropriate for meningococcal infections.

Choice B reason: For meningococcal infections, droplet precautions, including a standard face mask, are recommended for the first 24 hours of antimicrobial therapy.

Choice C reason: It is the responsibility of the healthcare facility to ensure that all staff members who require it are fitted for particulate filter masks, but this does not apply to droplet precautions for meningococcal infections.

Choice D reason: Sending the UAP for an immediate fitting for a particulate filter mask is unnecessary for droplet precautions and could delay essential care for the client.

A. Explain that since the medication is a controlled substance, it must be taken. B. Credit the medication back and put it in the client's medication box. C. Keep the medication and see if the client will want to take it later. D. Have another nurse witness the disposal of the medication into the disposal container.

Correct Answer is D

Explanation

Choice A reason: The nurse cannot force the client to take medication against their will, even if it is a controlled substance.

Choice B reason: Crediting the medication back and placing it in the client's medication box is not appropriate as the medication has already been removed from the unit dose wrapper.

Choice C reason: Keeping the medication to see if the client will want to take it later is not safe practice as it could lead to medication errors or misuse.

Choice D reason: The nurse should dispose of the medication properly, and having another nurse witness the disposal is a standard procedure to ensure that controlled substances are accounted for.

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When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (K+) 3.5 to 5 mEq/L (3.5 to 5 mmol/L)

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Correct Answer is B

Explanation

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When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?

Reference Range:
Potassium (K+) 3.5 to 5 mEq/L (3.5 to 5 mmol/L)