The nurse observes that the handgrip of the client with hypophosphatemia has diminished in strength since the last assessment 2 hours ago. What is the nurse's primary intervention?
a. Document the finding and continue to as-sess.
b. Assess respiratory status immediately.
c. Request an order for a serum calcium lev-el.
d. Administer a rapid bolus of intravenous phosphorus.
B
Decreased handgrip strength indicates worsening of hypophosphatemia and general muscle weakness. Muscle weakness can impair respiratory effort and reduce gas exchange to the point that the client becomes hypoxemic. IV phosphorus is given slowly to avoid rebound hyperphos-phatemia. Phosphorus and calcium exist in an inverse relationship, and the nurse might want to know the calcium level, but this is less important than ensuring that the client has adequate res-piratory function. Simply documenting the finding without intervening would not help the client.
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