Asked by Kadin Beler on Sep 24, 2024
Verified
The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now?
A) Raise bed side rails due to potential decreased level of consciousness and confusion.
B) Examine sacral area and patient's heels for skin breakdown due to potential edema.
C) Establish seizure precautions due to potential muscle twitching, cramps, and seizures.
D) Institute fall precautions due to potential postural hypotension and weak leg muscles.
Hypokalemia
A medical condition characterized by lower than normal levels of potassium in the bloodstream.
Seizure Precautions
Guideline actions and safety measures taken to protect individuals from injury during or after a seizure, focusing on the environment and direct care.
Postural Hypotension
A form of low blood pressure that occurs when standing up from sitting or lying down, causing dizziness or faintness.
- Identify the risks and necessary interventions for patients with electrolyte imbalances such as hyperkalemia or hypokalemia.
- Prioritize nursing interventions based on the severity of a patient’s condition and potential complications.
Verified Answer
NB
Natasha Beaver3 days ago
Final Answer :
D
Explanation :
Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.
Learning Objectives
- Identify the risks and necessary interventions for patients with electrolyte imbalances such as hyperkalemia or hypokalemia.
- Prioritize nursing interventions based on the severity of a patient’s condition and potential complications.