Medical Surgical Potassium K+ #3

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. Initiate seizure precautions.
    • Rationale:

      This answer is not correct because unlike other electrolyte alterations, hyperkalemia rarely causes symptoms in the central nervous system (CNS), and seizures do not occur; therefore, it is not appropriate for the nurse to initiate seizure precautions for this client based on the serum potassium results.

  2. Notify the healthcare provider of the results.
    • Rationale:

      This answer is not correct because the healthcare provider would likely question the results too; therefore, this is not an appropriate response by the nurse based on the current data.

  3. Encourage the client to increase the intake of bananas.
    • Rationale:

      This answer is not correct because bananas are a food high in potassium and would be recommended for the client with laboratory findings indicative of hypokalemia, not hyperkalemia.

  4. Question the results and have the specimen redrawn.
    • Rationale:

      This answer is correct because this is the best action by the nurse based on the initial and current serum potassium levels presented in this scenario. Hemolysis is often the cause for elevated serum potassium levels in the absence of other clinical manifestations.

Overview

The normal range for serum potassium is 3.5 to 5.5 mEq/L. A client who has no health problems being treated for cellulitis should have an elevated serum potassium level questioned.

Explanation

Learning Outcomes

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 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of hemolysis of the specimen. Therefore, the appropriate action by the nurse is to question the results and have the specimen redrawn.

Test Taking Tip

Consider all potential causes for the elevated potassium level to answer this question correctly.

Video Rationale