The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take?
Reference Range:
Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
Prepare to administer a glucose, then insulin, then potassium infusion.
Instruct the client to increase daily intake of potassium rich foods.
Inform the healthcare provider of the need for potassium replacement.
Change the plan of care to include hourly urinary output measurements.
The Correct Answer is C
A. The combination of glucose and insulin is used to shift potassium into cells, which would lower serum potassium levels further; this is not appropriate for treating hypokalemia.
B. Increasing dietary intake of potassium is important but not sufficient to correct a serum potassium level as low as 2.5 mEq/L, which requires more immediate intervention.
C. A potassium level of 2.5 mEq/L is critically low and can lead to life-threatening cardiac arrhythmias. The healthcare provider should be informed immediately to initiate potassium replacement therapy, likely via intravenous infusion.
D. Hourly urinary output measurements may be useful but are not the immediate priority in treating severe hypokalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
A. Hypertension is not a common side effect of phenytoin. It is not typically associated with the medication.
B. Peripheral edema is not commonly linked to phenytoin use.
C. Gingival hyperplasia, or overgrowth of the gums, is a common side effect of phenytoin, particularly with long-term use.
D. Hematuria is not a typical side effect of phenytoin and may indicate a different medical issue.
Correct Answer is B
Explanation
A. Rubber-soled slippers do not provide adequate support or stability for a client with weakness.
B. Tennis shoes with velcro offer good support, stability, and ease of use, which is important for clients with weakness or impaired mobility.
C. Leather-soled loafers may be slippery and do not provide as much support or stability.
D. Slip-on rubber shower shoes lack adequate support and can be unsafe for ambulation.
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