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 C
Explanation
Choice A reason: Calling the client's next of kin and having them provide verbal consent is not the appropriate action for the nurse to take. The client is an adult and has the right to make his own decisions about his health care. The nurse should respect the client's autonomy and not involve his family without his permission.
Choice B reason: The nurse can reinforce information but cannot provide the primary explanation of the procedure. The HCP must clarify any confusion before consent is valid.
Choice C reason: Informed consent requires that the client fully understands the procedure, risks, benefits, and alternatives before signing. The healthcare provider (HCP) is responsible for explaining the procedure, not the nurse. Since the client’s question indicates misunderstanding, the nurse must notify the provider so they can clarify the information before consent is obtained.
Choice D reason: Postponing the procedure until the client understands the risks/benefits is not the best action for the nurse to take. The cardiac catheterization may be a time-sensitive and necessary procedure for the client's condition. The nurse should not delay the procedure without a valid reason. The nurse should try to enhance the client's understanding and confidence before postponing the procedure.
Correct Answer is B
Explanation
Choice A reason: Offering to switch the nurse's shift assignments to afternoons or evenings is not the best approach for the nurse manager to use when addressing this staff member's tardiness. This may not address the underlying cause of the tardiness and may not be fair to other staff members who may prefer those shifts.
Choice B reason: Stressing the expectation that the nurse will arrive on time for all scheduled shifts is the best approach for the nurse manager to use when addressing this staff member's tardiness. This communicates the importance of punctuality and accountability and sets a clear standard for the nurse to follow.
Choice C reason: Cautioning the nurse that one more tardiness will result in probational employment is not the best approach for the nurse manager to use when addressing this staff member's tardiness. This may be too harsh and punitive for the first time the nurse manager addresses the issue and may not allow for any explanation or improvement from the nurse.
Choice D reason: Having the nurse sign a copy of the hospital employee attendance policy is not the best approach for the nurse manager to use when addressing this staff member's tardiness. This may be too passive and bureaucratic and may not convey the seriousness of the issue or the expectations of the nurse manager.
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