A male college student is brought to an emergency clinic by his friends because they report that he has been vomiting for the past two days as a result of food poisoning. Laboratory findings indicate that the client's potassium level is 2.5 mEq/L (2.5 mmol/L), so he is admitted to a local hospital. Which intervention is most important for the nurse to include in this client's plan of care?
Monitor client's electrocardiogram continuously.
Inject prescribed potassium chloride IV push slowly.
Assess level of consciousness every 4 hours.
Instruct client on dietary intake of potassium-rich foods.
The Correct Answer is A
Choice A reason: This is the most important intervention, as hypokalemia (low potassium level) can cause life-threatening cardiac arrhythmias and dysrhythmias. The nurse should monitor the client's electrocardiogram (ECG) for signs of abnormal heart rate and rhythm, such as bradycardia, tachycardia, atrial fibrillation, ventricular fibrillation, or asystole.
Choice B reason: This is not a good intervention, as potassium chloride should not be given IV push, as it can cause cardiac arrest. Potassium chloride should be given IV infusion, diluted in a compatible solution, and at a controlled rate, as prescribed by the provider.
Choice C reason: This is a relevant intervention, as hypokalemia can cause muscle weakness, fatigue, and confusion. The nurse should assess the client's level of consciousness (LOC) every 4 hours, and report any changes or deterioration to the provider.
Choice D reason: This is a helpful intervention, as potassium-rich foods can help restore the normal potassium level in the body. The nurse should instruct the client on dietary intake of potassium-rich foods, such as bananas, oranges, potatoes, tomatoes, spinach, yogurt, and nuts. However, this is not the most important intervention, as it may take longer to correct the hypokalemia than IV infusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Assuming care of the client and assigning the PN to the care of a different client is not the best action the nurse should take. This may undermine the PN's confidence and competence and create resentment and conflict.
Choice B reason: Acknowledging that the PN has positioned the client safely and correctly is not the best action the nurse should take. This may reinforce the incorrect positioning and lead to complications during the lumbar puncture.
Choice C reason: Arranging for an unlicensed assistive personnel to assist the PN during the procedure is not the best action the nurse should take. This may not address the root cause of the incorrect positioning and may not improve the PN's skills and knowledge.
Choice D reason: Demonstrating to the PN how to position the client more effectively for the procedure is the best action the nurse should take. This will correct the error and provide the PN with feedback and guidance on how to perform the task correctly in the future.
Correct Answer is A
Explanation
Choice A reason: Mumps is a highly contagious viral infection that spreads through respiratory droplets¹. Droplet precautions are necessary to prevent the transmission of the virus to other patients and staff. An isolation cart contains personal protective equipment (PPE) such as masks, gloves, and gowns that the nurse and visitors should wear when entering the room.
Choice B reason: Scheduling bedside play time with the occupational therapist may be beneficial for the child's development and well-being, but it is not the most important intervention. The child may be too sick or uncomfortable to engage in play activities, and the therapist may be exposed to the virus.
Choice C reason: Instructing the child's parents about the need for transmission precautions is an important intervention, but it is not the first one. The nurse should first ensure that the child is isolated and protected from spreading the infection, and then educate the parents about the signs, symptoms, and complications of mumps, as well as the preventive measures such as vaccination and hygiene.
Choice D reason: Assigning the child to a room close to the nurse's station may facilitate the monitoring and care of the child, but it is not the most important intervention. The child may be disturbed by the noise and activity near the station, and the risk of transmission may increase if the child is not isolated.
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