Medical Surgical Potassium K+ #19

Question

A client recovering from a cholecystectomy has a nasogastric tube, decreased reflexes, pulse of 110, weak and irregular, and blood pressure of 80/50 mm Hg. The client is weak, mildly confused, and has a serum of potassium level of 3 mEq/L. Based on the assessment data, which is the priority nursing action?

Answers

  1. Notify the healthcare provider.
    • Rationale:

      This answer is correct because the priority action by the nurse is to notify the healthcare provider regarding the client’s current clinical manifestations and laboratory findings as further evaluation is required for this client.

  2. Withhold the prescribed spironolactone.
    • Rationale:

      This answer is not correct because spironolactone is a potassium-sparing diuretic; therefore, it is inappropriate to withhold this prescribed medication as this medication will not further exacerbate the client’s hypokalemia.

  3. Instruct the client on foods high in potassium.
    • Rationale:

      This answer is not correct because while it is appropriate for the client to increase the amount of potassium in the diet, this is not the priority action by the nurse. The nurse must notify the healthcare provider regarding the client’s current clinical manifestation before implementing other treatment options.

  4. Administer a prescribed potassium supplement.
    • Rationale:

      This answer is not correct because while it is not inappropriate to administer the prescribed potassium supplement based on this data, this is not the priority action by the nurse. The nurse must notify the healthcare provider regarding the client’s current clinical manifestation before implementing other treatment options.

Overview

Potassium is a mineral and electrolyte that plays an important role in both nerve conduction and muscle contraction. The normal range for serum potassium within the body is 3.5 to 5 mEq/L. When the client’s serum potassium level is less than 3.5 mEq/L, hypokalemia is diagnosed.

Explanation

Learning Outcomes

The normal range for serum potassium within the body is 3.5 to 5 mEq/L. When the client’s serum potassium level is less than 3.5 mEq/L, hypokalemia is diagnosed. Signs of hypokalemia include a low blood pressure, heart irregularities, muscle twitching, weakness, and respiratory failure. When signs of hypokalemia occur with a low serum potassium level, the nurse notifies the healthcare provider before implementing any other treatment options.

Test Taking Tip

Priority indicates that all choices may be appropriate but only one is the most important for the nurse to implement based on the current client data.

Video Rationale