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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. Turn the overhead lights on while giving instructions. B. Stand behind the client to avoid intimidation. C. Provide handouts written at a 12th grade reading level. D. Use background music to promote relaxation.

Correct Answer is A

Explanation

Rationale:

A. Turning on overhead lights ensures that the client can see the instructions clearly, which is particularly important for older adults who may have visual impairments. Adequate lighting helps improve comprehension and reduces the risk of misunderstandings.

B. Standing behind the client may cause confusion or discomfort. It is better to face the client while communicating.

C. Handouts should be written at a lower reading level, typically around the 5th to 6th grade, to ensure that most clients can understand them, especially older adults.

D. Background music may be distracting rather than helpful during the provision of important instructions.

A. Assess for presence of a supernumerary breast nipple. B. Palpate for evidence of temporary gynecomastia. C. Calculate approximate age menstruation should occur. D. Use the Tanner staging to determine sexual maturity.

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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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 A

Explanation

Correct Answer is D

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 A

Explanation

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Correct Answer is D

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)]