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 D
Explanation
Choice A rationale
Referring to a support group is beneficial for long-term coping but does not address the immediate emotional impact of grief, which requires attentive listening and empathy to support the client emotionally.
Choice B rationale
Viewing the deceased's body might help with closure, but it should only be encouraged when the client feels ready. The priority is assessing emotional readiness and supporting them empathetically at that moment.
Choice C rationale
Building new relationships promotes long-term healing, yet it is premature at this stage of grief. Clients require acknowledgment of their immediate loss and support for their acute emotional response first.
Choice D rationale
Sharing thoughts and feelings facilitates emotional expression, which is critical in the acute phase of grief. It helps the client process the loss, providing an essential foundation for emotional support and further interventions.
Correct Answer is D
Explanation
Choice A rationale
Reporting elevated blood pressure is important; however, verifying the accuracy of the reading ensures reliable data before initiating any interventions or contacting the provider.
Choice B rationale
While baseline comparison is essential, rechecking ensures accuracy and rules out any transient factors or equipment errors causing the abnormal blood pressure reading.
Choice C rationale
Administering antihypertensives without confirming the abnormal reading may lead to potential hypotension or overtreatment if the initial measurement was inaccurate.
Choice D rationale
Rechecking the blood pressure confirms accuracy, rules out transient elevations or equipment issues, and provides reliable data for appropriate clinical decision-making and subsequent actions.
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