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Difficulty: MediumReduction of Risk Potential

A 54-year-old client is receiving continuous intravenous normal saline and has a nasogastric tube set to low intermittent suction to manage a mechanical bowel obstruction. The practical nurse reviews the morning laboratory results, noting a serum potassium level of 2.8 mEq/L and a serum sodium level of 138 mEq/L. The client reports severe muscle weakness and a "racing" heartbeat. Which action should the practical nurse take first?

  1. A
    Document the laboratory findings in the electronic health record and continue routine monitoring.
  2. Notify the registered nurse immediately regarding the laboratory results and cardiac symptoms.Answer
  3. C
    Clamp the nasogastric tube and auscultate the client's abdomen for bowel sounds.
  4. D
    Prepare and administer an intravenous potassium chloride bolus to correct the deficit.

Answer

Notify the registered nurse immediately regarding the laboratory results and cardiac symptoms.
A serum potassium level of 2.8 mEq/L is critically low (normal is 3.5-5.0 mEq/L) and places the client at immediate risk for life-threatening cardiac dysrhythmias, which is evidenced by the client's report of a racing heartbeat. The practical nurse must prioritize communicating this critical finding to the registered nurse or healthcare provider to facilitate immediate medical intervention.

Step-by-Step Solution

1
Analyze the laboratory results provided in the scenario.
The serum sodium of 138 mEq/L is normal, but the serum potassium of 2.8 mEq/L is critically low (the normal range is typically 3.5 to 5.0 mEq/L).
Identifying abnormal data is the first step in recognizing risk potential and prioritizing client care.
2
Correlate the client's symptoms with the abnormal laboratory findings.
The client's muscle weakness and racing heartbeat are classic signs of severe hypokalemia, indicating potential cardiac dysrhythmias.
Connecting physiological symptoms to laboratory data determines the clinical urgency of the situation.
3
Determine the priority nursing action based on the practical nurse's scope of practice.
The practical nurse must immediately escalate this critical finding to the registered nurse or healthcare provider.
Prompt communication is required to initiate life-saving medical interventions, such as controlled potassium replacement and continuous cardiac monitoring.

Key Concept

Recognizing and Escalating Critical Laboratory Values
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Topics

Reduction of Risk Potential

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