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Zorluk: OrtaReduction of Risk Potential

A practical nurse is caring for a client who is receiving continuous nasogastric (NG) tube suctioning for a mechanical bowel obstruction. During morning rounds, the client reports severe leg cramps and a fluttering sensation in the chest. The nurse assesses a blood pressure of 108/62108/62 mm Hg and an irregular heart rate of 112112 beats per minute. The most recent basic metabolic panel reveals a serum potassium level of 2.82.8 mEq/L (2.82.8 mmol/L). Which of the following actions should the nurse take first?

  1. A
    Document the laboratory values in the electronic health record and plan to reassess the vital signs in one hour.
  2. B
    Reassure the client that a fast heart rate is an expected physiological response to gastrointestinal discomfort.
  3. Notify the registered nurse immediately regarding the client's assessment findings and laboratory results.Cevap
  4. D
    Instruct the assistive personnel (AP) to assess the client's telemetry strip to determine the rhythm.

Cevap

The correct action is to notify the registered nurse immediately regarding the client's assessment findings and laboratory results.
Continuous nasogastric suctioning places the client at significant risk for electrolyte depletion, particularly hypokalemia. A serum potassium level of 2.82.8 mEq/L is critically low (normal range is 3.53.5 to 5.05.0 mEq/L). The presence of severe leg cramps, palpitations, and an irregular heart rate indicates symptomatic hypokalemia, which can rapidly progress to life-threatening cardiac dysrhythmias. Recognizing these risk factors and immediately escalating the critical findings to the registered nurse is the priority action for the practical nurse to ensure prompt medical intervention.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and laboratory data.
The client has a critically low serum potassium level (2.82.8 mEq/L) and is exhibiting signs of symptomatic hypokalemia, including muscle cramps, palpitations, and an irregular heart rate.
Continuous nasogastric suction removes potassium-rich gastric secretions, placing the client at high risk for electrolyte imbalances.
2
Determine the priority nursing action based on the practical nurse scope of practice.
The practical nurse must immediately escalate these critical findings to the registered nurse.
Symptomatic hypokalemia can lead to life-threatening cardiac dysrhythmias and requires prompt medical intervention (such as intravenous potassium replacement) which is outside the independent scope of the practical nurse.

Anahtar Kavram

Identifying and escalating critical laboratory values and symptomatic complications (Reduction of Risk Potential).
Tahmini Süre:1m 15s
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Reduction of Risk Potential

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