A new nurse has just completed orientation and is working on the medical unit. The new nurse is shadowing the charge nurse as they both care for a client with a potassium level of 6.3 mEq/L. Which action by the new nurse requires intervention by the charge nurse?

  • The nurse prepares to administer spironolactone (Aldactone) 25 mg PO.
  • The nurse delivers the client’s morning meal tray for a low-potassium diet.
  • The nurse administers sodium polystyrene sulfonate (Kayexalate) 15 g PO.
  • The nurse teaches the client the importance of ambulating, coughing, and deep-breathing.
Number 1 is correct.
Spironolactone is a potassium-sparing diuretic, which is inappropriate for this client. Furosemide (Lasix) is a better choice for this client, because it helps remove excess potassium. Delivering a low-potassium meal tray is an appropriate action. Sodium polystyrene sulfonate (Kayexalate) helps remove excess potassium from the body, and is often prescribed for clients who have elevated potassium levels. All clients should be ambulating, coughing, and deep-breathing as their condition permits.