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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. Applying pressure proximal to the IV site is not appropriate and could cause further complications.

B. Assessing the radial pulse is important but is not the immediate response to the occlusion alarm.

C. Straightening the arm can help relieve a positional occlusion, which is a common cause of such alarms.

D. Elevating the arm may help with venous return but is not a first-line action for addressing the occlusion alarm.

Correct Answer is A

Explanation

Rationale:

A. Acetaminophen, especially in high doses or with prolonged use, is known to cause hepatotoxicity, which can lead to jaundice. Notifying the healthcare provider is crucial to prevent further liver damage.

B. Captopril, an ACE inhibitor used for hypertension, is not commonly associated with jaundice or liver dysfunction.

C. Omeprazole, a proton pump inhibitor used for GERD, is less likely to cause liver damage compared to acetaminophen.

D. Prednisone, a corticosteroid, can have many side effects, but hepatotoxicity is not among the most common, making acetaminophen the most concerning drug in this context.

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