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 C

Explanation

A. Request a neurological consult: This is likely a metabolic issue (hypocalcemia), not a neurological disorder.

B. Have another nurse take their blood pressure: Rechecking BP does not address the underlying cause of the abnormal movement.

C. Review the client's lab values: Carpopedal spasm (Trousseau's sign) during BP measurement suggests hypocalcemia. The nurse should check serum calcium levels to confirm.

D. Call the healthcare provider for orders: The nurse should first review lab results to provide accurate data when notifying the provider.

A. Provide water for a client diagnosed with chronic kidney disease B. Instruct the client on appropriate fluid restrictions C. Measure the client's output from the indwelling catheter D. Record the client’s intake and output in the EMR

Correct Answer is B

Explanation

A. Provide water for a client diagnosed with chronic kidney disease: Fluid intake must be controlled in CKD. A nurse should determine if water intake is appropriate.

B. Instruct the client on appropriate fluid restrictions: Client education is a nursing responsibility and cannot be delegated to a UAP. The nurse should educate clients on fluid restrictions in conditions like chronic kidney disease (CKD) to prevent fluid overload and electrolyte imbalances.

C. Measure the client’s output from the indwelling catheter: This task can be delegated to a UAP.

D. Record the client’s intake and output in the EMR: UAPs can record I&O but cannot interpret the data.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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