A nurse is caring for a 60-year-old female client on a medical-surgical unit.
Which action should the nurse take first?
Administer potassium supplements as prescribed.
Notify the provider of the laboratory results.
Encourage the client to eat potassium-rich foods.
Monitor the client for signs of hyperkalemia.
The Correct Answer is B
Choice A rationale: Administering potassium supplements may be appropriate, but the nurse must first notify the provider to confirm the treatment plan. Unilateral administration without provider input could lead to incorrect dosing.
Choice B rationale: Notifying the provider of the laboratory results is the priority to ensure prompt medical evaluation and intervention. The provider will determine the appropriate course of action based on the client's clinical condition and lab results.
Choice C rationale: Encouraging the client to eat potassium-rich foods is not the initial action. Diet changes take time to affect potassium levels, and immediate intervention is required to address the hypokalemia.
Choice D rationale: Monitoring for signs of hyperkalemia is inappropriate since the client has low potassium levels. The priority is to manage hypokalemia and prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Sucking chest wounds impair oxygenation, posing a direct threat to life. Signs of shock (88/58 mm Hg, heart rate 115/min) demand immediate intervention. Red tag classification reflects life-threatening but treatable conditions needing priority care.
Choice B rationale
Significant penetrating head wounds with irregular breathing indicate brainstem damage, which usually leads to poor outcomes. Black tag assignment denotes expectant management due to un-survivable injuries.
Choice C rationale
Superficial lacerations with stable vitals (118/78 mm Hg) and occlusive dressing in place ensure no life-threatening issues. Green tag indicates minimal care urgency, requiring no immediate intervention.
Choice D rationale
Closed lower leg injuries causing severe pain do not compromise airway, breathing, or circulation. Yellow tag classification reflects delayed medical needs, prioritizing resources for more critical cases.
Correct Answer is A
Explanation
Choice A rationale
Nausea is a direct clinical manifestation of enteral feeding intolerance, often resulting from delayed gastric emptying or improper feeding rate, leading to gastrointestinal distress and potential aspiration risks.
Choice B rationale
A urine output of 40 mL/hr, while indicative of oliguria and potential renal compromise, is not associated with gastrointestinal intolerance to enteral feedings, as these involve different organ systems.
Choice C rationale
Soft stools are not a reliable indicator of feeding intolerance. They can occur due to dietary composition changes but are not associated with pathologic conditions needing intervention.
Choice D rationale
Headache is a nonspecific symptom that does not relate directly to feeding intolerance. Other causes, such as dehydration or systemic factors, are more likely culprits for this presentation.
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