A nurse is assessing a patient with hypokalemia, she notes that the patient's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?

Assess the patient’s respiratory rate, rhythm, depth

Call the healthcare provider

Document findings and monitor the patient

Measure the patient’s pulse and blood pressure

Answer and Explanation

The Correct Answer is A

A. Assess the patient’s respiratory rate, rhythm, depth:

This is the correct action to take first. Hypokalemia can lead to respiratory muscle weakness, which can result in respiratory compromise or failure. Assessing the patient's respiratory rate, rhythm, and depth will help determine if there are any signs of respiratory distress or impending respiratory failure.

B. Call the healthcare provider:

While it's important to involve the healthcare provider, especially if there is a significant change in the patient's condition, assessing the patient's immediate respiratory status takes priority to ensure prompt intervention if respiratory distress is present.

C. Document findings and monitor the patient:

Documenting findings and ongoing monitoring are essential steps, but they come after addressing the patient's immediate needs, such as assessing respiratory status in this case.

D. Measure the patient’s pulse and blood pressure:

While vital signs are important, they may not immediately address the potential respiratory compromise associated with hypokalemia-induced muscle weakness. Assessing respiratory status is more directly relevant to the observed change in handgrip strength.

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Correct Answer is D

Explanation

A. Evidence-based practice:

Evidence-based practice (EBP) involves integrating the best available evidence from research, clinical expertise, and patient preferences and values to inform nursing practice. In perioperative nursing, EBP is important for making informed decisions about preoperative, intraoperative, and postoperative care protocols. For example, using evidence-based guidelines for surgical site infection prevention, pain management strategies, and postoperative care protocols can improve patient outcomes and safety.

B. Informatics:

Informatics refers to the use of information technology and data management systems to support nursing practice, education, research, and patient care. In perioperative nursing, informatics plays a crucial role in managing electronic health records (EHRs), accessing patient data, documenting care, and communicating with interdisciplinary team members. It also includes utilizing perioperative information systems for surgical scheduling, anesthesia records, and tracking patient progress during surgery.

C. Quality improvement:

Quality improvement (QI) involves systematic processes to monitor, assess, and improve the quality of healthcare services. In perioperative nursing, QI initiatives focus on enhancing patient safety, optimizing surgical outcomes, reducing complications, and improving efficiency in perioperative processes. Nurses participate in QI projects by analyzing data, identifying areas for improvement, implementing evidence-based practices, and evaluating the impact of interventions on patient care and outcomes.

D. Safety:

Safety is a fundamental QSEN competency, particularly critical in perioperative nursing care. Perioperative nurses are responsible for ensuring the safety of patients during all phases of surgery, including preoperative assessment, intraoperative care, and postoperative recovery. This includes measures such as verifying patient identity and surgical site, preventing surgical errors (e.g., wrong-site surgery), maintaining aseptic techniques to prevent infections, preventing falls and injuries, managing anesthesia safely, and adhering to protocols for safe medication administration and equipment use.

A. Elevation of the head of the bed by 30 degrees B. Determining the amount of gasoline that the client encountered C. Asking the client when they last ate a meal D. Decontamination of the client

Correct Answer is D

Explanation

A. Elevation of the head of the bed by 30 degrees: While elevation of the head of the bed may be necessary for certain medical conditions, it is not the priority concern in a client with a gasoline burn. Decontamination and assessment of the burn injury take precedence.

B. Determining the amount of gasoline that the client encountered: While it's important to gather information about the circumstances of the injury, including the amount of gasoline involved, this is not the priority concern at the immediate moment. Decontamination and assessment of the burn take precedence over obtaining historical information.

C. Asking the client when they last ate a meal: While assessing the client's nutritional status and potential need for dietary interventions is important, it is not the priority safety concern in the context of a gasoline burn. Decontamination and assessment of the burn injury are more critical at this time.

D. Decontamination of the client

When a client sustains a gasoline burn, the priority safety concern is to decontaminate the client. Gasoline can cause chemical burns and can be absorbed through the skin, leading to systemic effects. Therefore, it's crucial to remove any remaining gasoline from the client's skin and clothing to prevent further absorption and minimize the risk of complications.

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A nurse is assessing a patient with hypokalemia, she notes that the patient's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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