A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan?

Give a dose of alendronate.

Administer furosemide.

Apply a cardiac monitor.

Monitor for Chvostek's sign.

Answer and Explanation

The Correct Answer is C

A. Give a dose of alendronate is incorrect. Alendronate is a medication used to treat osteoporosis, and it does not address low potassium levels. In this case, the focus should be on correcting the potassium imbalance.

B. Administer furosemide is incorrect. Furosemide is a diuretic that can cause further loss of potassium. In a client with low potassium levels (hypokalemia., administering furosemide could worsen the condition and lead to life-threatening complications.

C. Apply a cardiac monitor is correct. Hypokalemia (potassium level of 2.9 mEq/L) can cause significant cardiac arrhythmias, including ventricular tachycardia or fibrillation. Applying a cardiac monitor is essential for monitoring the client’s heart rhythm and detecting any abnormalities related to the low potassium level.

D. Monitor for Chvostek's sign is incorrect. Chvostek's sign is indicative of hypocalcemia, not hypokalemia. While both hypocalcemia and hypokalemia can cause neuromuscular excitability, monitoring for Chvostek’s sign is not a priority in the management of hypokalemia.

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Correct Answer is A

Explanation

A. Placing the client in an orthopneic position is correct. The orthopneic position (sitting upright and leaning forward. helps clients with COPD breathe more easily by maximizing lung expansion and easing the work of breathing. This position is often used in clients with chronic respiratory conditions to alleviate dyspnea.

B. Providing the client with three large meals is incorrect. Clients with COPD may have difficulty eating large meals because it can interfere with breathing due to increased diaphragm pressure. Instead, small, frequent meals are recommended to reduce the workload on the respiratory system.

C. Encouraging the client to cough and deep breathe once every 8 hr is incorrect. In clients with COPD, frequent coughing and deep breathing exercises are important to promote airway clearance and lung expansion. The nurse should encourage these activities more often than every 8 hours, especially to help clear mucus.

D. Limiting fluid intake to 1,000 ml daily is incorrect. Adequate hydration is essential in COPD clients to help thin secretions and promote easier expectoration. A restriction on fluids could lead to thickened mucus and worsened respiratory status.

A. Hold the irrigation solution bottle 5 cm (2 in) above the sterile container. B. Open the outer wrapper of the sterile package toward her body. C. Place the irrigation solution bottle cap on the sterile field. D. Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field.

Correct Answer is D

Explanation

A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.

B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.

C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.

D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.

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A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan?

Nursing Test Bank

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