The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now?
a. Raise bed side rails due to potential decreased level of consciousness and confusion.
b. Examine sacral area and patient's heels for skin breakdown due to potential edema.
c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures.
d. Institute fall precautions due to potential postural hypotension and weak leg muscles.
ANS: D
Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.
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