The client's potassium level is 2.2 What nursing action has the highest priority?

Administer supplemental oxygen

Secure precautions

Cardiac monitoring

Initiating a fluid restriction

Answer and Explanation

The Correct Answer is C

A. Administer supplemental oxygen: Hypokalemia primarily affects cardiac and neuromuscular function, not oxygenation. Oxygen may be needed if dysrhythmias develop but is not the highest priority.

B. Seizure precautions: While severe hypokalemia can cause muscle weakness, seizures are not the primary concern. Cardiac effects take priority.

C. Cardiac monitoring: A potassium level of 2.2 mEq/L is critically low, increasing the risk of life-threatening cardiac arrhythmias. Continuous cardiac monitoring helps detect dangerous dysrhythmias like ventricular tachycardia.

D. Initiating a fluid restriction: Fluid restriction is more relevant for hyperkalemia or fluid overload, not hypokalemia.

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Correct Answer is B

Explanation

A. ST depression: ST depression is associated with hypokalemia or ischemia.

B. Tall peaked T waves: Hyperkalemia (K+ > 5.0 mEq/L) causes tall, peaked T waves due to abnormal repolarization. Severe hyperkalemia (>6.5 mEq/L) can lead to cardiac arrest.

C. Prolonged ST segment: Not a characteristic of hyperkalemia.

D. Prominent U wave: A U wave is seen in hypokalemia, not hyperkalemia.

A. Hypotension B. Polyuria C. Weight loss D. Edema

Correct Answer is D

Explanation

A. Hypotension: Fluid overload typically causes hypertension, not hypotension.

B. Polyuria: ESRD patients typically have oliguria or anuria, not excessive urine output.

C. Weight loss: Fluid overload leads to weight gain due to fluid retention.

D. Edema: Fluid overload causes peripheral and pulmonary edema due to impaired kidney function. Clients may also experience hypertension, dyspnea, and crackles.

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The client's potassium level is 2.2 What nursing action has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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