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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)]

A.

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

B.

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

C.

Inform the healthcare provider of the need for potassium replacement.

D.

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

E.

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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Correct Answer is C

Explanation

Rationale:

A. Clamping the catheter before irrigation is not recommended as it could cause urine retention and increase the risk of infection.

B. An infusion pump is not typically used for catheter irrigation as manual control is preferred for monitoring flow and pressure.

C. Using a sterile syringe to gently irrigate the catheter with 20 mL of normal saline is the correct approach. This method helps to clear fibrin clots and sediment without applying excessive pressure, which could damage the bladder or catheter.

D. Power flushing with 60 mL could apply excessive pressure, potentially causing trauma to the bladder or urethra.

Correct Answer is A

Explanation

Rationale:

A. Spasms of the neck and back can be symptoms of acute dystonia, a side effect of antipsychotic medications like chlorpromazine. Anticholinergic drugs such as benztropine mesylate can help manage these symptoms.

B. Spasms are not an expected side effect of chlorpromazine and require intervention rather than acceptance.

C. Refusing to administer chlorpromazine without consulting the healthcare provider may be premature; the priority is to address the symptoms.

D. Decreasing the dose and notifying the healthcare provider may be necessary, but first, it’s essential to determine if anticholinergic medication is required to address the acute symptoms.

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