An adult client is receiving treatment for a fluid and electrolyte imbalance. The client's… — NCLEX-PN

An adult client is receiving treatment for a fluid and electrolyte imbalance. The client's medication administration record includes a scheduled daily dose of oral potassium chloride 20 mEq. Upon reviewing the morning electronic health record, the nurse notes a serum potassium level of $5.8 \text{ mEq/L}$ . Based on these findings, what is the appropriate action for the practical nurse (PN) to take?

Withhold the potassium chloride dose and report the laboratory finding to the supervising registered nurse.Answer
B
Administer the scheduled dose and document the elevated serum potassium level in the client's medical record.
C
Check the client's apical pulse for one full minute and then administer the medication as prescribed.
D
Calculate a proportionally reduced dose based on the laboratory results and administer that amount.

Answer

The practical nurse must withhold the potassium chloride dose and immediately notify the supervising registered nurse due to the hyperkalemic lab value.

The normal serum potassium range is

3.5

5.0 \text{ mEq/L}

. A level of

5.8 \text{ mEq/L}

indicates hyperkalemia. Administering additional potassium could lead to severe cardiac dysrhythmias. The practical nurse's scope of practice requires recognizing this critical abnormal finding, withholding the contraindicated medication, and escalating the information to the registered nurse or provider for further intervention.

Step-by-Step Solution

Evaluate the client's laboratory results against normal reference ranges.

The serum potassium level is

5.8 \text{ mEq/L}

, which is above the normal range of

3.5

5.0 \text{ mEq/L}

Identifying hyperkalemia is crucial before administering medications that affect potassium levels.

Determine the safety of administering the prescribed medication.

Potassium chloride is contraindicated in clients with hyperkalemia.

Giving additional potassium to a hyperkalemic client can lead to fatal cardiac arrhythmias.

Determine the appropriate nursing intervention within the PN scope of practice.

The PN must withhold the dose and escalate the critical finding.

The PN is responsible for recognizing abnormalities, withholding unsafe medications, and reporting to the RN or provider for further clinical decisions.

Key Concept

Safe Medication Administration: Recognizing and Acting on Critical Laboratory Values

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