The patient's laboratory report today indicates severe ...

[michelleunicorn]

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now?
 
  a. Raise bed side rails due to potential decreased level of consciousness and confusion.
  b. Examine sacral area and patient's heels for skin breakdown due to potential edema.
  c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures.
  d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

Question 2

The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the physician?
 
  a. Swollen ankles in patient with compensated heart failure
  b. Positive Chvostek's sign in patient with acute pancreatitis
  c. Dry mucous membranes in patient taking a new diuretic
  d. Constipation in patient who has advanced breast cancer

[frankwu0507]

Answer to Question 1

ANS: D
Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

Answer to Question 2

ANS: B
Positive Chvostek's sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek's sign.

[michelleunicorn]

TYSM

[nguyenhoanhat]

Gracias!