Level: Advanced
Difficulty: Hard
Subtopic: IV therapy and compatibility
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for continuous IV fluid therapy. Assessment da…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for continuous IV fluid therapy. Assessment data include the client has potassium 5.8 mEq/L with muscle weakness on the monitor. Which action should the nurse take first?
Question
A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.