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The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take?
Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Prepare to administer a glucose, then insulin, then potassium infusion.

Instruct the client to increase daily intake of potassium rich foods.

Inform the healthcare provider of the need for potassium replacement.

Change the plan of care to include hourly urinary output measurements.

Answer and Explanation

The Correct Answer is C

Rationale:

A. The combination of glucose and insulin is used to shift potassium into cells, which would lower serum potassium levels further; this is not appropriate for treating hypokalemia.

B. Increasing dietary intake of potassium is important but not sufficient to correct a serum potassium level as low as 2.5 mEq/L, which requires more immediate intervention.

C. A potassium level of 2.5 mEq/L is critically low and can lead to life-threatening cardiac arrhythmias. The healthcare provider should be informed immediately to initiate potassium replacement therapy, likely via intravenous infusion.

D. Hourly urinary output measurements may be useful but are not the immediate priority in treating severe hypokalemia.

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A. Remove the drainage bag and apply antibiotic ointment around the stoma. B. Apply a pulse oximeter to determine the client's oxygen saturation level. C. Replace the colostomy supplies with non-latex hypoallergenic supplies. D. Notify the healthcare provider of the appearance of the stoma immediately.

Correct Answer is D

Explanation

Rationale:

A. Applying antibiotic ointment is not appropriate for this situation as the issue is likely compromised blood flow, not infection.

B. Checking oxygen saturation is not related to the color change of the stoma.

C. Switching to non-latex supplies is important for clients with latex allergies but is not relevant to the immediate problem.

D. A dark red to bluish color of the stoma suggests compromised blood flow and possible ischemia, which requires immediate medical attention. The nurse should notify the healthcare provider immediately to address this potentially serious complication.

A. Left carotid pulse volume of 4+; right carotid pulse volume of 0. B. Left carotid artery bruit present; no bruit heard in right carotid artery. C. Left carotid artery has strong pulse; right carotid artery occluded. D. Left carotid artery occlusion present; no occlusion of right carotid artery.

Correct Answer is B

Explanation

Rationale:

A. Pulse volume and bruit are different assessments; pulse volume is not graded in the context of auscultation findings.

B. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, often due to stenosis or narrowing. Documenting a "left carotid artery bruit present" accurately reflects the findings.

C. The presence of a bruit does not necessarily mean the pulse is strong or that there is occlusion.

D. A bruit indicates turbulent flow, not necessarily complete occlusion.

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The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take?
Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

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Correct Answer is D

Explanation

Correct Answer is B

Explanation

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Take full exam for free The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

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In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

Correct Answer is D

Explanation

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

Correct Answer is B

Explanation

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The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take?
Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]