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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Calling for an assistant is the best action for the nurse to take. This can help the nurse maintain aseptic technique and ensure the safety of the client undergoing the lumbar puncture, while also allowing the nurse to respond to the code as soon as possible.

Choice B reason: Responding to the code is not the best action for the nurse to take. This may compromise the aseptic technique and the safety of the client undergoing the lumbar puncture, who may also experience complications or adverse reactions.

Choice C reason: Closing the room door is not the best action for the nurse to take. This may isolate the client undergoing the lumbar puncture and prevent the nurse from communicating or receiving assistance from other staff members.

Choice D reason: Finishing the procedure is not the best action for the nurse to take. This may delay the nurse's response to the code and jeopardize the survival of the client experiencing respiratory arrest, who needs immediate and effective resuscitation.

A. The client who had bilateral above-knee amputations, now has a sacral decubitus skin flap, and is receiving vancomycin intravenously. B. The client who is in end-stage Alzheimer's, who requires feeding, and is waiting for a long-term facility placement. C. The client who has pneumonia following a total knee replacement, and is receiving clarithromycin orally. D. The client who has right hemiplegia as the result of a cerebral vascular accident and receives continuous gastrostomy feedings per enteral pump.

Correct Answer is C

Explanation

The correct answer is c. The client who has pneumonia following a total knee replacement, and is receiving clarithromycin orally.

Choice A reason: This client has a complex wound care and an intravenous antibiotic therapy, which require the skills and knowledge of a registered nurse. Therefore, this client should not be assigned to a PN.

Choice B reason: This client has a chronic condition that does not require frequent assessment or intervention. Therefore, this client can be assigned to a UAP under the supervision of a nurse.

Choice C reason: This client has a stable condition that can be managed with oral medication and routine monitoring. Therefore, this client can be assigned to a PN who can administer oral drugs and report any changes to the nurse.

Choice D reason: This client has a high risk of aspiration and complications due to the enteral feeding and the neurological impairment. Therefore, this client should not be assigned to a PN.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting with a lumbar puncture on a client. During the procedure, a code is called for another client on the unit who is experiencing respiratory arrest. Which action should the nurse take?

Correct Answer is A

Explanation

The charge nurse is making assignments for a 15-bed skilled nursing unit with the staff of one nurse, two practical nurses (PN), and two unlicensed assistive personnel (UAP). Which client should be assigned to the PN?

Correct Answer is C

Explanation

The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?

The nurse-manager overhears an older female nurse complaining to a co-worker about the time being used to attend an in-service session for bioterrorism preparedness. How should the nurse-manager respond?

It is most important for the charge nurse to schedule a multi-disciplinary team meeting to discuss which client?

The charge nurse is assigning care to clients who are all receiving continuous intravenous medication infusions. The client receiving which medication infusion is best to assign to the licensed practical nurse (PN), rather than an RN?

After implementation of new policies related to client identification prior to medication administration, the frequency of medication errors remains unchanged. Which should be the nurse manager's next action?

A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?