Safe, Effective Care Environment
57. Following report on four clients, the priority intervention for a nurse should be to:
Safe, Effective Care Environment
57. Following report on four clients, the priority intervention for a nurse should be to:
. Request an antiemetic for a client who has been vomiting during the night.
. Report a K+ level of 5.9 in a client receiving Kayexalate.
. Complete the assessment of the four clients.
. Notify the family that the client with chest pain was now in ICU.
Test-Taking Tip
Consider which client is at greatest risk for a life-threatening consequence.
Content Area: Adult Health, Triage; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
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Answer 1 is incorrect because there is no indication that this client is the most unstable of the four clients. Answer 2 is correct because the K+ level is above the normal high of 5.5 mEq/L. An elevated K+ can have serious effects on the heart and affect the stability of the client. The physician needs to be called regarding the report so that changes in treatment can be made to manage the elevated K+. Answer 3 is incorrect because it is the client with the elevated K+ who is at risk for life-threatening arrhythmias, and the K+ level needs to be reported right away. Answer 4 is incorrect because the client sent to ICU is receiving close observation. The family of this client definitely needs to be contacted after reporting the client with the elevated K+ level.