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 C
Explanation
Choice A rationale
Dry skin is not directly associated with the acute stress response, which activates the sympathetic nervous system, leading instead to physiological changes like increased sweating or oily skin.
Choice B rationale
Increased urinary output is not indicative of stress but may suggest conditions like diabetes or diuretic use. Stress typically activates the fight-or-flight response, causing decreased renal activity and urinary retention.
Choice C rationale
Dilated pupils occur due to sympathetic nervous system activation during stress, which enhances visual acuity by allowing more light into the eyes as part of the fight-or-flight response.
Choice D rationale
Hyperactive bowel sounds are linked to increased parasympathetic activity and not stress, which is characterized by reduced gastrointestinal motility due to sympathetic nervous system activation.
Correct Answer is A
Explanation
Choice A rationale
A bed alarm is a safety device that alerts staff when a client is attempting to get out of bed, reducing the risk of falls while maintaining the client’s autonomy and dignity.
Choice B rationale
Maintaining the bed in the lowest position minimizes fall risk upon exiting the bed, but it alone does not provide proactive monitoring, thus limiting its preventive effectiveness in dementia clients.
Choice C rationale
Vest restraints physically restrict movement and are associated with risks like pressure injuries or decreased circulation. They are considered a last resort and not routinely recommended for dementia clients.
Choice D rationale
Sedatives increase fall risk due to drowsiness and cognitive impairment, which could exacerbate symptoms in dementia. They are not the preferred intervention for safety concerns in this context.
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