Level: Foundational
Difficulty: Easy
Subtopic: Vitamins and minerals
NCLEX: A 58-year-old client after a stroke is being evaluated for nursing care related to vitamins and minerals. Assessm…
Nutrition Basic Care and Comfort
Case Study
A 58-year-old client after a stroke is being evaluated for nursing care related to vitamins and minerals. Assessment data include the client has potassium 5.9 mEq/L while asking about salt substitutes. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that has potassium 5.9 mEq/L while asking about salt substitutes.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that has potassium 5.9 mEq/L while asking about salt substitutes.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that has potassium 5.9 mEq/L while asking about salt substitutes.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.