Examkin

Question

Difficulty: EasyPhysiological Adaptation

A practical nurse is reviewing morning laboratory results for an adult client with a history of heart failure who is receiving a daily loop diuretic. The client's serum potassium level is 2.8 mEq/L (2.8 mmol/L). Which action should the nurse take first?

  1. A
    Document the finding in the client's medical record for the provider to review during routine rounds.
  2. Promptly notify the registered nurse and the healthcare provider about the laboratory result.Answer
  3. C
    Administer the next scheduled dose of the loop diuretic with a glass of potassium-rich orange juice.
  4. D
    Ask the client to rate any generalized muscle aches or pain on a numeric scale of 0 to 10.

Answer

Promptly notify the registered nurse and the healthcare provider about the laboratory result.
The correct answer addresses the urgent need to report a critically low serum potassium level. Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Severe hypokalemia can lead to life-threatening cardiac dysrhythmias. Immediate escalation ensures that the client receives prompt medical intervention, such as intravenous potassium replacement and the temporary discontinuation of the potassium-wasting diuretic.

Step-by-Step Solution

1
Identify the normal reference range for serum potassium.
The expected normal range is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).
This establishes a baseline to evaluate the significance of the client's laboratory results.
2
Evaluate the client's specific laboratory value.
A value of 2.8 mEq/L (2.8 mmol/L) indicates severe hypokalemia.
Loop diuretics commonly cause potassium wasting, leading to this expected but dangerous imbalance.
3
Determine the priority nursing intervention based on the practical nurse's scope of practice.
The nurse must immediately escalate this critical finding to the registered nurse or healthcare provider.
Severe hypokalemia can cause fatal cardiac dysrhythmias, making this a time-sensitive physiological emergency that requires immediate medical intervention.

Key Concept

Electrolyte Imbalances (Hypokalemia) and Critical Value Escalation
Rate this question

Topics

Physiological Adaptation

More questions from this topic