A client with heart failure (HF) returns to the clinic two weeks after adjustments were made to the prescribed cardiac glycoside, diuretic, and potassium supplement. The client's lungs are clear, heart rate is 58 beats/minute, and serum potassium level is 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?

Reference Range:

Potassium (K+) [3.5 to 5.0mEq/L (3.5 to 5.0 mmol/L)]

Compare the weight with what it was at last visit.

Report serum potassium to healthcare provider.

Review the dietary history from the past week.

Check the pretibial areas and ankles for edema.

Answer and Explanation

The Correct Answer is B

A.   While weight monitoring is important for heart failure management, it's not the priority in this situation. The low potassium level is a more immediate concern.
B.   The serum potassium level of 2.9 mEq/L is significantly below the normal range and indicates hypokalemia. Hypokalemia can lead to serious cardiac arrhythmias, especially in patients taking cardiac glycosides. This is a critical finding that requires immediate attention from the healthcare provider.
C.   Dietary intake can contribute to potassium levels, but it's not the most urgent action at this time.
D.   Assessing for edema is important for monitoring heart failure status, but it's not the priority when there's a critical electrolyte imbalance.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This is the most crucial information to provide. A scleral buckling procedure is performed to repair a retinal detachment. Any signs of detachment recurrence are critical and should be reported immediately. Directly addresses the primary goal of the surgery.
B. While maintaining the head in a specific position is often recommended post-surgery, it's not the most critical information in this context. The focus should be on identifying potential complications. Not as critical as the other options.
C. Infection is a potential complication of any surgery, but it's not the primary concern immediately post-scleral buckling. Important but not the most critical information.
D. Ambulation is generally encouraged to prevent complications like pneumonia and deep vein thrombosis, but it's not a specific concern immediately post-scleral buckling. Not directly related to the procedure.

A. Discard the incorrectly dialed dose and recalibrate the insulin pen. B. Save the dialed dose and prepare the correct dose using a syringe C. Assist the client to administer 24 units of the dialed dose, and waste the remainder. D. Advise the client to dial down to the correct dose, which can then be administered.

Correct Answer is A

Explanation

A. Administering an incorrect dose of insulin can lead to hypoglycemia, a serious complication. Discarding the incorrectly dialed dose ensures patient safety. Directly addresses the error and prevents potential harm.
B. This option is inefficient and increases the risk of error. It's unnecessary to use both a pen and a syringe for a single dose. Does not address the immediate issue of the incorrect dose.
C. Administering more insulin than prescribed is dangerous and can lead to hypoglycemia. Wasting the remainder doesn't address the core issue of the incorrect dose. Increases the risk of hypoglycemia.
D. Insulin pens are designed to be precise. Dialing down to the correct dose after an error can compromise the accuracy of the dose. Does not ensure accurate dosing.

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Naxlex Comprehensive Predictor Exams

A client is scheduled for a scleral buckling procedure after previously having multiple laser coagulation procedures done for retinal tears. Which Information about the immediate postoperative period should the nurse provide this client?

Correct Answer is A

Explanation

When learning to use an insulin pen, a client with diabetes dials 28 units of regular insulin instead of 24 units, the prescribed dose. Which action should the nurse take?

Correct Answer is A

Explanation

An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?

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