A nurse is caring for a client with dementia who frequently tries to get out of bed. Which of the following actions should the nurse take?

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.

Choice A rationale

Cyanotic mucous membranes and oxygen saturation of 84% indicate severe hypoxemia. Normal oxygen saturation is 95–100%. The cyanosis suggests inadequate tissue oxygenation, requiring immediate intervention to prevent respiratory failure.

Choice B rationale

Diffuse wheezing and tremors may signify severe airway obstruction or beta-agonist overuse. While concerning, these findings are not as immediately life-threatening as hypoxemia and cyanosis.

Choice C rationale

Elevated blood pressure (168/90 mm Hg) and heart rate (98/min) may indicate stress or pain but do not reflect acute life-threatening changes compared to severe hypoxemia.

Choice D rationale

Clear rhinorrhea and warm, dry skin may suggest mild upper respiratory infection. These findings do not indicate imminent danger or severe respiratory compromise compared to hypoxemia and cyanosis.