A nurse in a medical unit has noted that a client's potassium level is elevated at 6.1 mEq/L. The nurse has notified the physician, removed the banana from the client's lunch tray, and is performing a focused assessment
When questioned by the client for the rationale for these actions, which of the following explanations is most appropriate?
A)
"Your potassium level is high, and so I need you let me know if you feel numbness, tingling, or weakness."
B)
"Your potassium levels in the blood are higher than they should be, which brings a risk of changes in the brain function."
C)
"I'll need to monitor you today for signs of high potassium; tell me if you feel as if your heart is beating quickly or irregularly."
D)
"The amount of potassium in your blood is too high, but this can be resolved by changing the intravenous fluid you are receiving."
Ans:
A
Feedback:
Paresthesia and muscle weakness are manifestations of hyperkalemia. Tachycardia and dysrhythmias are more commonly associated with hypokalemia, and the greatest risks associated with potassium imbalances are cardiac rather than neurological. Hyperkalemia is not normally resolved by correction using IV fluid.
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