A 72-year-old client is admitted with hyponatremia and is started on an infusion of 3 After four hours, the nurse notes that the client's blood pressure has increased to 156/92 mm Hg, respiratory rate is 24/min, and oxygen saturation is 91 On physical assessment, the nurse hears new-onset crackles in the lower lung fields and observes +2 pitting edema in both ankles.
The client appears restless and mildly confused, has a urine output of only 200 mL over the last four hours, and has gained 1.2 kg (2.6 pounds) since admission. Which of the following actions should the nurse take?

Choice A rationale

Excessive water intake, or psychogenic polydipsia, can lead to dilutional hyponatremia rather than a primary deficit in potassium levels. While significant fluid shifts can occur, the kidneys usually compensate by excreting dilute urine. Normal serum potassium ranges from 3.5 to 5.0 mEq/L. In this case, the client’s level of 3.0 mEq/L indicates hypokalemia. Drinking 4 liters of water daily is generally handled by healthy renal mechanisms without causing such a specific drop in potassium.

Choice B rationale

Most commercial salt substitutes are formulated using potassium chloride instead of sodium chloride to help patients reduce their sodium intake. Using these products typically increases the risk of developing hyperkalemia, where potassium levels exceed 5.0 mEq/L. It would not be a causative factor for this client’s hypokalemic state of 3.0 mEq/L. Consuming salt substitutes provides an exogenous source of the mineral, making a deficiency highly unlikely unless there were extreme malabsorption or concurrent diuretic use.

Choice C rationale

Nasogastric suctioning is a classic cause of hypokalemia because gastric fluids are rich in potassium, hydrogen, and chloride ions. Continuous removal of these secretions directly depletes the body’s potassium stores. Furthermore, the loss of gastric acid can lead to metabolic alkalosis, which causes an intracellular shift of potassium, further lowering the serum concentration below the normal 3.5 to 5.0 mEq/L range. The client’s level of 3.0 mEq/L is a direct consequence of these combined physiological losses.

Choice D rationale

Spironolactone is categorized as a potassium-sparing diuretic that acts as an aldosterone antagonist in the distal renal tubules. Unlike loop or thiazide diuretics, spironolactone inhibits the excretion of potassium, which usually results in an increase in serum levels. It is often prescribed to prevent or treat hypokalemia. Therefore, the use of this medication would not cause a low potassium level of 3.0 mEq/L but would instead be a reason for the level to stay high.

Choice B rationale

Pain is a subjective, multidimensional experience that can only be truly defined by the person experiencing it. The self-report is considered the gold standard and the most reliable indicator of pain intensity because it accounts for individual thresholds and cultural influences. Relying on the client's own rating, often using a 0 to 10 scale, ensures that the nurse addresses the pain as it is perceived, which leads to more accurate and effective pharmacological and nonpharmacological interventions.

Choice A rationale

Vital signs such as heart rate, blood pressure, and respiratory rate often increase in response to acute pain due to sympathetic nervous system activation. However, these physiological markers are not specific to pain and can be influenced by anxiety, hypovolemia, or infection. Furthermore, the body eventually adapts to chronic or prolonged pain, meaning vital signs may return to normal ranges despite the client still experiencing significant discomfort. Therefore, they should never replace the client's own verbal report.

Choice C rationale

Nonverbal signs such as grimacing, guarding, or restlessness provide helpful clues, especially in clients who are non-communicative or cognitively impaired. However, many individuals may not exhibit these signs due to cultural norms, coping mechanisms, or the use of sedative medications. Relying solely on observation can lead to the undertreatment of pain, as the absence of visible distress does not equate to the absence of pain. Observations should supplement, but not supersede, the client's direct communication.

Choice D rationale

While the nature and invasiveness of a surgical procedure can help a nurse anticipate the likely level of postoperative pain, it does not account for individual variability in pain perception or the effectiveness of anesthesia. Two clients undergoing the exact same procedure may report vastly different levels of pain intensity based on their unique biological and psychological profiles. Assuming pain levels based on the procedure type risks ignoring the actual needs and personal experience of the recovering client.