A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which intervention should the nurse implement first?

The client's serum potassium level is elevated at 6.0 mEq/L (6.0 mmol/L), which is above the normal reference range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

Hyperkalemia can have significant cardiac implications, including the potential for life-threatening dysrhythmias. Therefore, close monitoring of the serum potassium level is crucial to assess the effectiveness of interventions and ensure that potassium levels are within a safe range.

While monitoring glucose levels before and after meals is important for clients receiving insulin therapy, in this scenario, the primary concern is the elevated potassium level.

The nurse should prioritize frequent assessment of the serum potassium level to guide appropriate management and prevent complications associated with hyperkalemia.

Monitoring and documenting strict intake and output are important for assessing fluid balance and renal function, but in this case, the elevated potassium level takes precedence as it poses a more immediate risk to the client's well-being.

Obtaining a 12-lead electrocardiogram (ECG) daily may be indicated in some cases of hyperkalemia, as certain ECG changes can be associated with elevated potassium levels. However, the more critical aspect is monitoring the potassium level itself, as ECG changes can occur rapidly and may not always be detectable on a daily basis.

A.Correct- The nurse should provide the parents with the phone numbers and websites of local organizations that offer support and counseling for families who have experienced a traumatic event. The nurse should also encourage the parents to seek professional help if they feel overwhelmed, depressed, or anxious.

B.Correct- Educating the parents about pool safety is crucial to prevent future accidents. This information can include guidelines for supervision, barriers, and measures to prevent drowning incidents.

C.Incorrect- While it's important for parents to be aware of the seriousness of child neglect, including this information in pre-discharge education might not be the most appropriate time, especially if the child is showing only minor signs of impact from the incident. This could increase their guilt and distress and damage the therapeutic relationship. The nurse should focus on providing support and education, not judgment or punishment.

D.Correct- The nurse should advise the parents to schedule a follow-up visit with the child's pediatrician within a week of discharge. The nurse should explain that the pediatrician will monitor the child's recovery and check for any signs of complications, such as brain damage, infection, or lung injury.

F. Correct- Assessing the parent's coping skills can help identify if they are dealing with any emotional stress or trauma related to the incident. Providing appropriate support or referrals if needed can be beneficial.