Which action would the nurse implement first for a client with a serum potassium level that has increased to 5.8 mEq/L (5.8 mmol/L) ?
A. Call the laboratory to repeat the test.
B. Take vital signs and notify the health care provider.
C. Inform the cardiac arrest team to place them on alert.
D. Take an electrocardiogram and have lidocaine available

The expected range for one's serum potassium level is between 3.5 and 5 mEq/L. Results above this range constitute a condition known as hyperkalemia, in which the patient's blood currently has an excess supply of potassium. This excess supply can cause cardiac dysrhythmias because of potassium's role in the regulation of the heart muscle's contractions and the rhythm at which the heart beats.

The dysrhythmia (abnormal rhythm) it may cause can be recorded on an electrocardiogram (ECG), evident by peaked T waves in each QT interval. The nurse will want to have the intravenous (IV) anti-arrhythmic medication lidocaine at-the-ready because of its propensity to suppress the depolarization of the ventricles that the extra potassium is manifesting in within the electrical activity of the heart.

Therefore, the priority action for the nurse to implement is to take an electrocardiogram and have lidocaine available, option D.

triharsh1007 triharsh1007 · Answer 2 · 2024-04-14T10:15:21+02:00

The first action for a client with a high potassium level of 5.8 mEq/L is to take vital signs and notify the healthcare provider. This is due to the significant risks associated with hyperkalemia, especially on heart function. Hence the correct option is B.

If a client's serum potassium level has increased to 5.8 mEq/L, the first action by a nurse should be to take vital signs and notify the health care provider. This is a critical situation because hyperkalemia can severely affect the function of muscles, the nervous system, and most importantly, the heart, potentially leading to fatal outcomes. Vital signs will help assess the urgency of the situation, and contacting the provider is essential for immediate management. It's also relevant to prepare for potential complications, such as arrhythmias, hence having the cardiac arrest team on alert and equipment for an electrocardiogram (EKG) and emergency medications like lidocaine could be subsequent steps following the initial actions. Hence the correct option is B.