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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. Clamp the catheter for 30 minutes prior to irrigating. B. Slowly irrigate catheter with saline using an infusion pump. C. Use a sterile syringe to irrigate with 20 mL normal saline. D. Power flush with 60 mL to remove mucous obstructions.

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.

A. Coronary artery bypass procedure was performed in 1995. B. Colonoscopy performed for routine screening six months ago. C. Digoxin and furosemide daily since 1996. D. Suffered with depression following death of spouse in 1999.

Correct Answer is C

Explanation

Rationale:

A. The history of coronary artery bypass surgery is important but does not directly relate to the current symptoms.

B. A recent colonoscopy is not relevant to the client's current symptoms.

C. Long-term use of digoxin and furosemide is highly significant as these medications can lead to digoxin toxicity, especially in the context of dehydration or renal insufficiency. Symptoms like nausea, vomiting, and anorexia are classic signs of digoxin toxicity.

D. A history of depression is important but not immediately relevant to the current symptoms of nausea, vomiting, and anorexia.

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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 C

Explanation

Correct Answer is C

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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Correct Answer is C

Explanation

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Correct Answer is C

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)]