Electrolytes Question #28

Question

A client without health problems is being treated for cellulitis of the hand. The client’s serum potassium level upon admission was 4.5 mEq/L however the most recent level is 7 mEq/L. Which action should the nurse take?

Answers

  1. Notify the healthcare provider of the results.
    • Rationale:
  2. Question the results and have the specimen redrawn
    • Rationale:
  3. Encourage the client to increase the intake of bananas
    • Rationale:
  4. Initiate seizure precautions
    • Rationale:

Overview

Explanation

The correct answer is B. A client who has no health problems being treated for cellulitis should have an elevated serum potassium level questioned. When the serum potassium level increases from 4.5 mEq/L to 7.0 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of hemolysis of the specimen. The healthcare provider would likely question results also. Bananas are a food high in potassium. Seizures are not a clinical manifestation of hyperkalemia.

NCLEX TIP: Using critical thinking is recommended when reading priority questions. Recognizing key words in the answer choices will allow you to know how to choose the correct answer for the question. Go through each answer choice and decide is it: Maslow’s hierarchy, safety-related, or following the nursing process (ADPIE). Never complete a nursing action that is outside the scope of practice.

Learning Outcomes

Test Taking Tip

Video Rationale