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. While assessing bowel sounds is important, it is not the highest priority in this situation. The client's low serum potassium level indicates the potential for serious cardiac arrhythmias, so actions related to monitoring and addressing this electrolyte imbalance are more critical.

Choice B reason:

Initiate cardiac monitoring for the client is the correct answer. A serum potassium level of 2.8 mEq/L is significantly low and can lead to life-threatening cardiac arrhythmias. Initiating cardiac monitoring is crucial to assess the client's heart rhythm and ensure that any potential abnormalities are identified promptly.

Choice C reason:

Check the client's hand grasps should not be implemented. Assessing the client's hand grasps can provide information about muscle strength, but it is not the immediate priority when the client has a critically low potassium level.

Choice D reason:

Administer an IV potassium drip should not be implemented. Administering IV potassium is important for correcting the potassium imbalance, but the priority is to assess and monitor the client's cardiac status first. Rapid administration of potassium can lead to cardiac arrhythmias, so it's important to ensure the heart's stability through cardiac monitoring before administering potassium.

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Correct Answer is A

Explanation

Choice A reason:

Confirming the correct position of the line by obtaining a blood sample is appropriate. Inserting a central venous catheter is a procedure that involves placing a catheter into a large vein, typically in the neck, chest, or groin. Confirming the correct placement is crucial to prevent complications such as pneumothorax (lung collapse) or catheter misplacement.

Choice B reason:

Instructing the client to cough as the catheter is inserted is not a standard practice during central venous catheter insertion and could lead to unnecessary complications.

Choice C reason:

Placing the head of the client's bed lower than the foot (Trendelenburg position) is not a standard practice during central venous catheter insertion and would not be helpful for this procedure.

Choice D reason:

Cleansing the site with hydrogen peroxide is not the recommended method for central venous catheter insertion. Typically, a sterile technique and appropriate antiseptic solution are used to reduce the risk of infection.

A. Place the client in high-Fowler's position. B. Chill the dialysate before administration C. Hang the drainage bag below the client's abdomen. D. Use clean technique to access the catheter

Correct Answer is A

Explanation

Choice A Reason:

Placing the client in high-Fowler's position is the appropriate action. When administering peritoneal dialysis, the nurse should place the client in a high-Fowler's position. This position helps promote the flow of dialysate into and out of the peritoneal cavity and assists with proper drainage. The high-Fowler's position allows for gravity to aid in the movement of fluid and helps prevent leakage of fluid back into the catheter.

Choice B Reason:

Chilling the dialysate before administration is not necessary and could cause discomfort to the client. Dialysate should be warmed to body temperature before use.

Choice C Reason:

Hanging the drainage bag below the client's abdomen is incorrect. The drainage bag should be positioned below the level of the abdomen to allow for proper drainage by gravity, but it should not be hung too low as this can lead to excessive drainage and dehydration.

Choice D Reason:

Using clean technique to access the catheter is incorrect. Sterile technique is required when accessing the peritoneal dialysis catheter to prevent infection. Peritoneal dialysis involves direct access to the peritoneal cavity, which is considered a sterile body cavity.

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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 preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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