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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 A

Explanation

Rationale:

A. Dysphagia, or difficulty swallowing, significantly increases the risk of aspiration, especially when consuming a full liquid diet that may not be easily controlled in the mouth. Aspiration can lead to serious complications, such as aspiration pneumonia.

B. Oxygen administration via a face mask does not typically increase the risk of aspiration unless the client has underlying conditions affecting swallowing.

C. Sensory aphasia affects communication but does not directly impact the swallowing mechanism, so it poses less risk of aspiration compared to dysphagia.

D. While clients with a nasogastric tube may be at some risk for aspiration, the risk is lower compared to a client with dysphagia actively consuming liquids.

Correct Answer is D

Explanation

Rationale:

A. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.

B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.

C. Recent international travel is unrelated to the development of senile lentigines.

D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.

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