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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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View Related questions

Correct Answer is C

Explanation

Rationale:

A. Palpating muscle tone is important but should be done in conjunction with resistance testing to assess strength.

B. Asking the client to close his eyes is not necessary for assessing muscle strength.

C. Applying resistance while the client extends and flexes his arms helps evaluate the muscle strength and function accurately.

D. Providing an object to hold is not relevant for assessing muscle strength in this context.

Correct Answer is D

Explanation

Rationale:

A. The presence of a supernumerary breast nipple is not related to the onset of menarche and is not a common assessment in determining sexual maturity.

B. Temporary gynecomastia is more commonly observed in adolescent boys rather than preteen girls.

C. While age can provide a rough estimate, it is not as accurate as a physical assessment of sexual maturity.

D. The Tanner staging is a reliable method used to assess sexual maturity in adolescents. It includes evaluating the development of breasts, pubic hair, and other secondary sexual characteristics, which can help determine if the client has likely reached menarche.

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