Level: Foundational
Difficulty: Easy
Subtopic: Cardiac disorders
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for heart failure exacerbation. The nurse revi…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for heart failure exacerbation. The nurse reviews this trend: potassium trending from 4.0 to 5.6 mEq/L with muscle weakness. Which interpretation and action are most appropriate?
Question
A. Ignore the trend because one data point can be explained later.
B. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
B. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
Rationale
Correct answer: B. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.