A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

Listen to the client's bowel sounds.

Initiate cardiac monitoring for the client.

Check the client's hand grasps.

Administer an IV potassium drip.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Listening to the client's bowel sounds should not be implemented. It is important for assessing the gastrointestinal status, but the priority in this situation is to address the potential cardiac complications of hypokalaemia.

Choice B reason:

Initiating cardiac monitoring for the client should be implemented. A serum potassium level of 2.8 mEq/L is significantly low (normal range is typically around 3.5-5.0 mEq/L). Low potassium levels, known as hypokalaemia, can lead to serious cardiac arrhythmias and other complications. Therefore, the nurse should prioritize cardiac monitoring to assess for any potential changes or abnormalities in the client's heart rhythm due to the low potassium levels.

Choice C reason:

Checking the client's hand grasps should not be implemented. It is a test for muscle strength and can be indicative of hypokalaemia, but initiating cardiac monitoring is more critical at this point.

Choice D reason:

Administering an IV potassium drip may be necessary, but initiating cardiac monitoring takes precedence as the first action to ensure the client's heart rhythm is stable before addressing the potassium imbalance.

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Correct Answer is B

Explanation

Choice A Reason:

"This finding may indicate possible medication toxicity." - The red-orange colour change in bodily fluids from rifampin is not indicative of medication toxicity.

Choice B Reason:

"This is an expected adverse effect of this medication." Rifampin is an antibiotic commonly used to treat tuberculosis. One of the well-known side effects of rifampin is the discoloration of bodily fluids, including saliva, tears, sweat, and urine, to a red-orange colour. This is a harmless and expected adverse effect of the medication and is not a sign of toxicity or other serious concerns.

Choice C Reason:

"Your provider will prescribe a different medication regimen." - There is no need to change the medication regimen based solely on the colour change of bodily fluids. This is an expected effect of rifampin.

Choice D Reason:

"You will need to increase your fluid intake to resolve this problem." - Increasing fluid intake will not resolve the colour change caused by rifampin. The client should be educated about the benign nature of the side effects instead.

A. Initiate a continuous IV insulin infusion. B. Begin bicarbonate continuous IV infusion. C. Check potassium levels D. Administer 0.9% sodium chloride

Correct Answer is A

Explanation

Choice A reason:

Initiating a continuous IV insulin infusion is the first priority. The priority intervention for a client in diabetic ketoacidosis (DKA) is to normalize blood glucose levels and reverse the ketoacidosis. Initiating a continuous IV insulin infusion is essential to rapidly lower the elevated blood glucose levels and counteract the metabolic acidosis associated with DKA.

Choice B reason:

Beginning a bicarbonate continuous IV infusion is generally not the priority in DKA management. While metabolic acidosis is a concern in DKA, insulin therapy and fluid resuscitation are typically the initial focus of treatment.

Choice C reason:

Checking potassium levels is important since potassium imbalances are common in DKA. However, while this is important, it is not the first priority. It's important to ensure that insulin therapy has been initiated before addressing potassium levels.

Choice D reason:

Administering 0.9% sodium chloride (normal saline) is a crucial part of DKA treatment but it is not the first priority as it helps correct dehydration and electrolyte imbalances. However, starting insulin therapy to address the underlying metabolic issue takes precedence.

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A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

Correct Answer is A

Explanation

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