Level: Foundational
Difficulty: Easy
Subtopic: Autonomy and informed consent
NCLEX: A 58-year-old client on a telemetry unit is being evaluated for nursing care related to autonomy and informed con…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 58-year-old client on a telemetry unit is being evaluated for nursing care related to autonomy and informed consent. 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. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Wait for a critical value or sentinel event before taking any nursing action.
D. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Wait for a critical value or sentinel event before taking any nursing action.
D. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale
Correct answer: D. 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.