Level: Advanced
Difficulty: Hard
Subtopic: Medication reconciliation
NCLEX: A 55-year-old client in postanesthesia care is being evaluated for transfer from another facility with multiple h…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 55-year-old client in postanesthesia care is being evaluated for transfer from another facility with multiple home medications. Assessment data include the client has potassium 5.8 mEq/L with muscle weakness on the monitor. 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. Routine data unchanged from the prior assessment.
D. The new finding that has potassium 5.8 mEq/L with muscle weakness on the monitor.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that has potassium 5.8 mEq/L with muscle weakness on the monitor.
Rationale
Correct answer: D. The new finding that has potassium 5.8 mEq/L with muscle weakness on the monitor.
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.