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Zorluk: OrtaReduction of Risk Potential

A client is receiving continuous nasogastric (NG) suctioning for a small bowel obstruction. While reviewing the morning electronic health record, the practical nurse (PN) notes a serum potassium level of 2.8 mEq/L2.8 \text{ mEq/L} (2.8 mmol/L2.8 \text{ mmol/L}) and a current apical pulse of 105 beats/min105 \text{ beats/min}. Which action should the PN take first?

  1. A
    Document the findings in the client's chart and continue routine bedside monitoring.
  2. Notify the registered nurse (RN) immediately about the laboratory value and the elevated heart rate.Cevap
  3. C
    Initiate a continuous intravenous infusion of potassium chloride to correct the deficit.
  4. D
    Reassess the apical pulse in two hours since the tachycardia is currently mild.

Cevap

Notify the registered nurse (RN) immediately about the laboratory value and the elevated heart rate.
The correct answer involves immediately notifying the RN. A serum potassium level of 2.8 mEq/L2.8 \text{ mEq/L} is critically low (normal is 3.5 to 5.0 mEq/L3.5 \text{ to } 5.0 \text{ mEq/L}) and places the client at severe risk for cardiac dysrhythmias. The mild tachycardia (105 beats/min105 \text{ beats/min}) may be an early sign of cardiac irritability. The PN must escalate these findings to the RN so that prompt medical intervention, such as electrolyte replacement, can be initiated.

Adım Adım Çözüm

1
Analyze the morning laboratory result.
The serum potassium level is 2.8 mEq/L2.8 \text{ mEq/L}, which is significantly below the normal range of 3.5 to 5.0 mEq/L3.5 \text{ to } 5.0 \text{ mEq/L}.
Identifying critical laboratory values is essential for recognizing risk potential.
2
Evaluate the current vital signs in the context of the laboratory result.
The apical pulse is 105 beats/min105 \text{ beats/min}, indicating mild tachycardia.
Hypokalemia can lead to life-threatening cardiac dysrhythmias, and tachycardia may be an early indicator of cardiovascular compromise.
3
Determine the appropriate scope of practice for the practical nurse (PN).
The PN must report these critical findings to the RN for further assessment and to receive new orders.
Initiating intravenous electrolyte replacement or performing advanced cardiac assessments falls outside the PN scope, requiring immediate escalation.

Anahtar Kavram

Reduction of Risk Potential: Recognizing critical laboratory values and escalating to the RN.
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Reduction of Risk Potential

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