Question

A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level is 4.5 mEq/L. What action should the nurse implement?

A) Notify the healthcare provider.
B) Decrease the IV solution flow rate.
C) Document the finding as the only action.
D) Administer potassium replacement as prescribed.

Answer 1

The nurse should document the finding as the only action for a client with a normal serum potassium level of 4.5 mEq/L post-CABG surgery. No other immediate action is necessary as this value is within the typical range of 3.5 to 5.0 mEq/L.

Step-by-step explanation:

If a client with a history of hypertension, myocardial infarction, and heart failure who is post-coronary artery bypass graft (CABG) surgery has a serum potassium level of 4.5 mEq/L, the nurse should document the finding as the only action (C). This is because a potassium level of 4.5 mEq/L falls within the normal range, which is typically between 3.5 to 5.0 mEq/L. There is no need for immediate action such as notifying the healthcare provider, decreasing the IV solution flow rate, or administering potassium replacement.

It is essential to understand that maintaining the correct serum potassium level is crucial for patients, especially following major surgeries like CABG since potassium plays a key role in cardiac function, and both hypokalemia and hyperkalemia can have serious consequences. For reference, in emergency cases where a patient presents with hypokalemia (low potassium levels), intravenous potassium chloride (KCl) may be administered. However, in the scenario provided, the client's potassium level is normal.