A nurse in the ER is caring for a patient who had fallen at home. She reviews the blood pressure reading of 160/80 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

To calculate the amount of potassium chloride (K-Dur) solution to administer, we need to use the following formula:

mL to administer = ordered dose (mEq) / available dose (mEq/mL) x mL

Plugging in the values from the question, we get:

mL to administer = 60 mEq / (20 mEq / 15 mL) x 15 mL

Simplifying the equation, we get:

mL to administer = 60 mEq x 15 mL / 20 mEq

mL to administer = 45 mL

Therefore, the nurse should administer 45 mL of potassium chloride (K-Dur) solution to the patient.

A. The client attempted to climb over the side rails and fell:

This statement includes an interpretation of the client's actions. It's important to focus on factual information without making assumptions about the client's intentions or actions.

B. The client was restless and trying to get out of bed all evening:

Describing the client as restless and trying to get out of bed is a subjective interpretation of the client's behavior. Factual and objective observations are preferred when documenting incidents.

C. The presence of a bed alarm could have prevented the client from falling:

This statement includes an interpretation and a suggestion for prevention. While prevention strategies are important to consider, an incident report should primarily focus on describing what actually occurred rather than suggesting what could have prevented it.

D. The client was lying on the floor next to his bed:

This statement provides a clear and objective description of the situation without making assumptions or interpretations. It is important to document the actual events and the client's current condition.