The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?

Client's serum pH is 7.41

Client has a stage 2 sacral wound

Client requires continuous nasogastric suction

Client has a history of adrenal insufficiency

Answer and Explanation

The Correct Answer is C

A. Client's serum pH is 7.41: This is within the normal range for blood pH (7.35-7.45) and does not specifically indicate a potassium deficit.
B. Client has a stage 2 sacral wound: This is related to skin integrity and does not directly impact potassium levels.
C. Client requires continuous nasogastric suction: Continuous nasogastric suction can lead to the loss of potassium as it removes gastric contents, which may include electrolytes.
D. Client has a history of adrenal insufficiency: While adrenal insufficiency can affect electrolyte balance, continuous nasogastric suction is a more immediate risk for potassium deficit.

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Correct Answer is C

Explanation

A. Crush the medication and administer it through the tube: Crushing sustained-release medications can disrupt their intended release mechanism, leading to potential overdose or ineffective treatment.
B. Provide the medication orally for the client to swallow: This option is not suitable since the client has a gastrostomy tube, and oral administration is not appropriate.
C. Ask the healthcare provider to prescribe the medication as an elixir for tube administration: This is the correct approach, as an elixir form of the medication would be appropriate for administration through the gastrostomy tube without altering its release properties.
D. Dissolve the medication in water and administer it through the tube: Dissolving sustained-release tablets can compromise their intended release mechanism, which may lead to complications.

A. Record intake and output B. Assess bowel sounds C. Obtain routine vital signs D. Document the presence of edema

Correct Answer is ["A","C","D"]

Explanation

A. Record intake and output: This task is within the UAP's scope of practice as it involves documenting fluid balance.

B. Assess bowel sounds: This task requires clinical judgment and assessment skills and should be performed by a licensed nurse.

C. Obtain routine vital signs: This is appropriate for the UAP to perform, as it involves routine measurements that do not require clinical assessment.

D. Document the presence of edema: The UAP can document observable findings such as edema, which is within their scope of practice.

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The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?

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