The nurse is assisting with a lumbar puncture on a client. During the procedure, a code is called for another client on the unit who is experiencing respiratory arrest. Which action should the nurse take?
Call for an assistant.
Respond to the code.
Close the room door.
Finish the procedure.
The Correct Answer is A
Choice A reason: Calling for an assistant is the best action for the nurse to take. This can help the nurse maintain aseptic technique and ensure the safety of the client undergoing the lumbar puncture, while also allowing the nurse to respond to the code as soon as possible.
Choice B reason: Responding to the code is not the best action for the nurse to take. This may compromise the aseptic technique and the safety of the client undergoing the lumbar puncture, who may also experience complications or adverse reactions.
Choice C reason: Closing the room door is not the best action for the nurse to take. This may isolate the client undergoing the lumbar puncture and prevent the nurse from communicating or receiving assistance from other staff members.
Choice D reason: Finishing the procedure is not the best action for the nurse to take. This may delay the nurse's response to the code and jeopardize the survival of the client experiencing respiratory arrest, who needs immediate and effective resuscitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not a correct assignment because the PN cannot obtain a report on a client with unstable angina, which is a complex and potentially life-threatening condition that requires the RN's assessment and intervention.
Choice B reason: This is not a correct assignment because the UAP cannot assist with the thoracentesis, which is an invasive and high-risk procedure that requires the RN's or the healthcare provider's skills and knowledge.
Choice C reason: This is not a correct assignment because the RN should not leave the unit to obtain report on a new admission while a thoracentesis is being performed. The RN should be available to monitor the client's vital signs, oxygen saturation, and potential complications during and after the procedure.
Choice D reason: This is a correct assignment because the PN can go to the ED to obtain report and transport the client with unstable angina, which is within the PN's scope of practice. The UAP can prepare the room for the new admission, which is a simple and routine task. The RN can assist with the thoracentesis, which is an advanced and critical skill.
Correct Answer is A
Explanation
Choice A reason: This is the most important intervention, as hypokalemia (low potassium level) can cause life-threatening cardiac arrhythmias and dysrhythmias. The nurse should monitor the client's electrocardiogram (ECG) for signs of abnormal heart rate and rhythm, such as bradycardia, tachycardia, atrial fibrillation, ventricular fibrillation, or asystole.
Choice B reason: This is not a good intervention, as potassium chloride should not be given IV push, as it can cause cardiac arrest. Potassium chloride should be given IV infusion, diluted in a compatible solution, and at a controlled rate, as prescribed by the provider.
Choice C reason: This is a relevant intervention, as hypokalemia can cause muscle weakness, fatigue, and confusion. The nurse should assess the client's level of consciousness (LOC) every 4 hours, and report any changes or deterioration to the provider.
Choice D reason: This is a helpful intervention, as potassium-rich foods can help restore the normal potassium level in the body. The nurse should instruct the client on dietary intake of potassium-rich foods, such as bananas, oranges, potatoes, tomatoes, spinach, yogurt, and nuts. However, this is not the most important intervention, as it may take longer to correct the hypokalemia than IV infusion.
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