Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?
A. Hold the prescribed dose and notify the provider of the serum potassium level.
This action would be appropriate if the potassium level were high, indicating hyperkalemia. However, since the client's potassium level is low, the nurse should administer the KCl as prescribed to address the hypokalemia. If there are any concerns about the rate or method of administration, or if the client shows signs of potassium-related complications, the nurse should then consult the provider.
B. Call the lab to verify the client's results.
Calling the lab to verify the client's results may seem like a reasonable action, but it's not the most appropriate in this scenario. Serum potassium levels are commonly measured accurately, and the nurse should prioritize clinical judgment based on the current potassium level in conjunction with the client's condition and medication regimen.
C. Give the ordered KCL as prescribed.
A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L), indicating hypokalemia. Hypokalemia can have serious consequences, including muscle weakness, cardiac arrhythmias, and other complications. Administering potassium chloride (KCl) as prescribed is necessary to correct this deficiency and prevent potential adverse effects associated with low potassium levels.
D. Omit the KCL dose and document that it was not given.
Simply omitting the KCL dose without informing the healthcare provider of the client's low potassium level could lead to a missed opportunity for appropriate intervention. Documenting the omission is essential for accurate record-keeping, but it's crucial to communicate the situation to the provider for further guidance.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med surg exam 1A Proctored Exam. Take the full exam now
Full Explanation
Correct answer: C
A. This action would be appropriate if the potassium level were high, indicating hyperkalemia. However, since the client's potassium level is low, the nurse should administer the KCl as prescribed to address the hypokalemia. If there are any concerns about the rate or method of administration, or if the client shows signs of potassium-related complications, the nurse should then consult the provider.
B. Calling the lab to verify the client's results may seem like a reasonable action, but it's not the most appropriate in this scenario. Serum potassium levels are commonly measured accurately, and the nurse should prioritize clinical judgment based on the current potassium level in conjunction with the client's condition and medication regimen.
C. A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L), indicating hypokalemia. Hypokalemia can have serious consequences, including muscle weakness, cardiac arrhythmias, and other complications. Administering potassium chloride (KCl) as prescribed is necessary to correct this deficiency and prevent potential adverse effects associated with low potassium levels.
D. Simply omitting the KCL dose without informing the healthcare provider of the client's low potassium level could lead to a missed opportunity for appropriate intervention. Documenting the omission is essential for accurate record-keeping, but it's crucial to communicate the situation to the provider for further guidance.
Similar Questions
A nurse is assessing a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?
A. Hypertension
B. Bradycardia
C. Peripheral edema
D. Oliguria
Hypovolemia is characterized by a decrease in circulating blood volume, which can lead to reduced urine output (oliguria) as the body tries to conserve fluid. Hypertension is not a typical finding in hypovolemia. Instead, hypotension (low blood pressure) is commonly observed. Bradycardia (slow heart rate) is not typically associated with hypovolemia. Instead, tachycardia (rapid heart rate) may be present as the body compensates for decreased blood volume. Peripheral edema is not a common finding in hypovolemia. Instead, fluid shifts from the interstitial spaces to maintain blood volume, leading to decreased tissue perfusion and potential signs of dehydration.
A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding?
A. A medication is being administered IV through the injection site closest the client.
Medications and blood should never be mixed in the same line because it can cause reactions, interference with the blood product, and complications for the client. Medications should be administered through a separate IV line or a port further away from the client.
B. The blood has been infusing steadily for 5 hr with no client symptoms.
Blood transfusions should typically be completed within 2 to 4 hours to reduce the risk of bacterial contamination and ensure that the blood does not exceed a safe infusion duration.
C. The packed RBCs are connected by Y tubing to normal saline.
Y tubing is commonly used for blood transfusions, where one arm of the Y is used for the packed RBCs and the other is for normal saline. Normal saline is used to flush the line before and after administering blood, ensuring the infusion is free of air and that the blood flows smoothly without clotting.
D. The drip chamber with filter is filled completely with blood.
The drip chamber should not be completely filled with blood. It should have a small amount of blood for monitoring the infusion rate, but the filter within the drip chamber is designed to filter any clots or debris. A completely filled chamber with blood can make it difficult to assess the flow rate, and could indicate that the blood is not flowing properly.
Full Explanation
A. Medications and blood should never be mixed in the same line because it can cause reactions, interference with the blood product, and complications for the client. Medications should be administered through a separate IV line or a port further away from the client.
B. Blood transfusions should typically be completed within 2 to 4 hours to reduce the risk of bacterial contamination and ensure that the blood does not exceed a safe infusion duration.
C. Y tubing is commonly used for blood transfusions, where one arm of the Y is used for the packed RBCs and the other is for normal saline. Normal saline is used to flush the line before and after administering blood, ensuring the infusion is free of air and that the blood flows smoothly without clotting.
D. The drip chamber should not be completely filled with blood. It should have a small amount of blood for monitoring the infusion rate, but the filter within the drip chamber is designed to filter any clots or debris. A completely filled chamber with blood can make it difficult to assess the flow rate, and could indicate that the blood is not flowing properly.
A nurse is instructing a group of clients regarding calcium rich foods. Which of the following foods should the nurse include in the teaching as the best source of calcium?
A. 1⁄2 cup ice cream
B. 1 cup cottage cheese
C. 1 cup milk
Milk is an excellent source of calcium. It provides a significant amount of calcium per serving and is readily available and commonly consumed. One cup of milk typically contains around 300 mg of calcium. Consuming milk regularly can help meet the body's calcium needs. The other options listed also contain calcium but may not provide as much calcium as 1 cup of milk: 1⁄2 cup ice cream: Ice cream does contain calcium, but it is also high in sugar and fat. Consuming excessive amounts of ice cream may not be the healthiest choice for obtaining calcium. 1 cup cottage cheese: Cottage cheese is a good source of calcium, but the calcium content can vary. It generally provides less calcium than a cup of milk. 1 ounce Swiss cheese: Swiss cheese does contain calcium, but the amount provided per ounce is generally lower compared to 1 cup of milk. In summary, 1 cup of milk is the best source of calcium among the options provided. It is important to note that there are also other calcium-rich foods available, such as yogurt, fortified plant-based milk, leafy greens, and calcium-fortified foods.
D. 1 ounce swiss cheese