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: Vitamin D is a fat-soluble vitamin that helps the body absorb calcium and phosphorus, which are essential for bone health. The main source of vitamin D is exposure to sunlight, which triggers the skin to produce it. The nurse should advise the client to spend at least 15 minutes outdoors every day, preferably in the morning or evening, when the sun is not too strong. The client should also wear sunscreen and protective clothing to prevent sunburn and skin damage.
Choice B reason: Reducing the amount of cereal in the diet is not a good recommendation for increasing vitamin D intake. Cereal is often fortified with vitamin D and other nutrients, such as iron and folic acid. The nurse should encourage the client to choose cereals that are high in vitamin D and low in sugar and fat. The client should also consume other foods that are rich in vitamin D, such as fatty fish, egg yolks, cheese, and mushrooms.
Choice C reason: Increasing intake of dietary calcium is important for preventing and treating osteoporosis, but it does not directly affect vitamin D intake. Calcium is a mineral that helps build and maintain strong bones and teeth. The nurse should recommend the client to consume foods that are high in calcium, such as dairy products, leafy greens, nuts, and tofu. The client should also take a calcium supplement if needed, as prescribed by the provider.
Choice D reason: Adding a regular exercise routine is beneficial for improving overall health and well-being, but it does not directly influence vitamin D intake. Exercise helps strengthen the muscles and bones, prevent falls and fractures, and reduce the risk of chronic diseases. The nurse should suggest the client to engage in moderate physical activity for at least 30 minutes a day, three times a week. The client should choose exercises that are appropriate for their age and fitness level, such as walking, swimming, or yoga.
Correct Answer is C
Explanation
Choice A reason: This is not the correct answer because reassessing the patient is not the next step after completing an assessment. Reassessment is done periodically or when there is a change in the patient's condition, but not immediately after the initial assessment.
Choice B reason: This is not the correct answer because writing nursing interventions is not the next step after completing an assessment. Nursing interventions are the actions that the nurse plans and implements to achieve the desired outcomes for the patient. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
Choice C reason: This is the correct answer because analyzing cues is the next step after completing an assessment. Analysis is the process of identifying patterns, relationships, and trends in the assessment data, and comparing them with the normal and expected findings. Analysis helps the nurse to identify the patient's problems, needs, strengths, and risks.
Choice D reason: This is not the correct answer because creating SMART goals is not the next step after completing an assessment. SMART goals are the specific, measurable, achievable, realistic, and time-bound outcomes that the nurse and the patient agree on. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
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