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.
Change the plan of care to include hourly urinary output measurements.
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 B
Explanation
Rationale:
A. Storing the remainder of the medication in a locked drawer is not appropriate for controlled substances that are not fully administered.
B. Lorazepam is a controlled substance, and any unused portion must be disposed of according to hospital policy, typically by discarding it with a witness. The presence of another nurse to witness the discarding process ensures proper documentation and compliance with legal regulations.
C. Withdrawing the medication into a syringe and labeling it is unsafe as it may lead to medication errors or misuse.
D. Simply throwing the vial into the trash, even with another nurse present, does not comply with the proper disposal procedure for controlled substances.
Correct Answer is C
Explanation
Rationale:
A. Baclofen should not be stopped abruptly as it can cause withdrawal symptoms. The client should consult their healthcare provider before using other antispasmodic.
B. Monitoring intake and output every 8 hours is not specific to baclofen administration.
C. Baclofen can cause dizziness, drowsiness, and hypotension. Advising the client to move slowly and cautiously when rising and walking helps prevent falls or injury due to these side effects.
D. While muscle strength assessment is important, it is not required every 4 hours and does not specifically address the common side effects of baclofen.