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 A

Explanation

A. Chloride level would be decreased: Metabolic alkalosis is often associated with hypochloremia, especially when caused by vomiting or diuretics. However, hypokalemia is more clinically significant.

B. Sodium level would be elevated: Sodium levels are not directly affected by metabolic alkalosis.

C. Magnesium level would be elevated: Magnesium levels are not significantly altered in metabolic alkalosis.

D. Potassium level would be decreased: A bicarbonate level of 30 mEq/L indicates metabolic alkalosis. In alkalosis, hydrogen ions shift out of the cells, and potassium moves into the cells, leading to hypokalemia.

A. Confusion B. Kussmaul's Respirations C. Seizures D. Paresthesia in the extremities

Correct Answer is A

Explanation

A. Confusion: Respiratory acidosis (low pH + high PaCO2) leads to decreased oxygenation of brain tissues, causing confusion, drowsiness, and lethargy.

B. Kussmaul's Respirations: Seen in metabolic acidosis, not respiratory acidosis.

C. Seizures: Seizures are more common with alkalosis (high pH) due to neuronal excitability.

D. Paresthesia in the Extremities: More common in respiratory alkalosis due to calcium shifts.

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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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