The RN receives a call from the lab that a client's potassium chloride (KCl) level is 6.6 (normal range is 3.5 to 5 mEq/L). What should the nurse do first?
Stop the KCl infusion
Administer oral KCl
Encourage fluids for dilution
Call the pharmacy
The Correct Answer is A
Choice A reason: This is the correct answer because stopping the KCl infusion is the first and most urgent action that the nurse should take. A high level of potassium in the blood, or hyperkalemia, can cause life-threatening cardiac arrhythmias and muscle weakness. The nurse should stop the source of excess potassium, which is the KCl infusion, and monitor the client's vital signs, electrocardiogram, and symptoms.
Choice B reason: This is not the correct answer because administering oral KCl is not the first or appropriate action that the nurse should take. Oral KCl would increase the potassium level in the blood, which is already too high. The nurse should avoid giving any potassium supplements or foods that are high in potassium, such as bananas, oranges, and potatoes.
Choice C reason: This is not the correct answer because encouraging fluids for dilution is not the first or effective action that the nurse should take. Fluids alone would not lower the potassium level in the blood, but rather dilute the concentration of other electrolytes, such as sodium and calcium. The nurse should administer fluids only as prescribed by the physician, and in conjunction with other treatments, such as diuretics, insulin, or sodium bicarbonate.
Choice D reason: This is not the correct answer because calling the pharmacy is not the first or priority action that the nurse should take. Calling the pharmacy may be necessary to obtain the medications that can lower the potassium level in the blood, such as diuretics, insulin, or sodium bicarbonate. However, the nurse should first stop the KCl infusion and notify the physician, who will order the appropriate medications and dosages.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Weight-bearing exercise, such as walking, jogging, or dancing, helps to strengthen the bones and prevent osteoporosis. It also improves muscle strength, balance, and coordination, which can reduce the risk of falls and fractures.
Choice B reason: Having a bone density scan every year is not necessary for a young adult client who has a family history of osteoporosis. A bone density scan is a test that measures the amount of calcium and other minerals in the bones. It is usually recommended for women over 65 years old, men over 70 years old, or people who have risk factors for osteoporosis, such as low body weight, smoking, or steroid use.
Choice C reason: Taking a magnesium supplement every day is not a proven way to prevent osteoporosis. Magnesium is a mineral that is involved in bone formation and metabolism, but there is not enough evidence to support its role in preventing or treating osteoporosis. A balanced diet that includes foods rich in calcium, vitamin D, and other nutrients is more effective for bone health.
Choice D reason: Drinking a cup of coffee every morning is not a good idea for a young adult client who has a family history of osteoporosis. Coffee contains caffeine, which can interfere with the absorption of calcium and increase the excretion of calcium in the urine. This can lead to lower bone density and higher risk of osteoporosis. Moderate coffee consumption (one or two cups per day) may not have a significant effect on bone health, but excessive coffee intake (more than four cups per day) should be avoided.
Correct Answer is D
Explanation
Choice A reason: Using soap to clean the client's skin is not a recommended action, as it can dry out and irritate the skin, increasing the risk of skin breakdown and infection.
Choice B reason: Applying friction when drying the client's skin is not a recommended action, as it can damage and abrade the skin, causing pain and inflammation.
Choice C reason: Using hot water to clean the client's skin is not a recommended action, as it can increase the blood flow and inflammation to the skin, as well as remove the natural oils that protect the skin.
Choice D reason: Applying a barrier cream to the client's skin is a recommended action, as it can moisturize and protect the skin from the effects of urine, such as acidity, bacteria, and enzymes.
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