# Situation: A 67-year-old man is on the medical ward on day 4 after an ischemic stroke with right-sided weakness. The ward uses a problem-oriented record with nursing progress notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation), kept in an electronic health record. At 14:00 the laboratory staff calls the nurse by phone with a critical serum potassium result for him and is still on the line. What should the nurse do FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630558  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 67-year-old man is on the medical ward on day 4 after an ischemic stroke with right-sided weakness. The ward uses a problem-oriented record with nursing progress notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation), kept in an electronic health record.

At 14:00 the laboratory staff calls the nurse by phone with a critical serum potassium result for him and is still on the line. What should the nurse do FIRST?

## 보기

1. Call the attending physician and report the result
2. Record in the notes the time the result was received
3. Assess the client for signs related to the result
4. Write down the result and read it back to the caller **✔ 정답**

**정답: 4**

## 해설

A critical result received by phone is written down and read back to the caller before the call ends, so that any error is caught at the source. The nurse then reports it promptly to the responsible provider and documents who was notified and when.

## 심화 해설

Write down and read back first
At 14:00 the laboratory staff calls with a critical serum potassium result, and the caller is still on the line. The first action is to write down the result and read it back to the caller before the call ends, so that any error is caught at its source. A potassium value misheard by a single digit could lead to giving or withholding treatment wrongly, with dangerous effects on heart rhythm. Read-back is a form of closed-loop communication: the receiver repeats the information and the sender confirms it is correct.

What follows the read-back
Once the value is confirmed, the nurse reports it promptly to the responsible provider, assesses the client for related signs such as muscle weakness, arrhythmias, or changes on the cardiac monitor, and documents the result, the time it was received, the name of the caller, who was notified, when, and any orders received. Many hospitals set a time limit for reporting critical results to the provider. The order of actions matters: confirm, report, assess, and document, with assessment often happening alongside reporting.

| Action | When | Reason |
| --- | --- | --- |
| Write down and read back | First, while caller is on the line | Catches errors at the source |
| Report to the provider | Next, promptly | Treatment depends on the provider |
| Assess the client | With or after reporting | Identify related signs |
| Document | After confirming and reporting | Record time, caller, notification |

Why the other actions are not first
Calling the attending physician right away is important, but reporting an unconfirmed value risks passing on an error. Recording the time received is part of documentation, which follows confirmation and reporting. Assessing the client is appropriate, but once the caller hangs up, the chance to confirm the value directly is lost. The read-back takes only seconds and protects every later step.

Link to communication safety
Read-back is required for verbal and telephone orders and critical test results in many safety standards. For this client after an ischemic stroke, the potassium result may relate to medications such as diuretics or to intake; either way, the provider needs the correct value.

Exam takeaway
Key point Critical result by phone: write it down and read it back before the call ends, then report, assess, and document.

## 임상 시나리오

Receiving a Critical Result by PhoneWrite down and read back
When the laboratory calls with a critical result, the nurse writes it down and reads it back while the caller is still on the line.

This closed-loop communication catches errors at the source before anyone acts on a misheard value.

Then report promptly to the provider, assess the client, and document the time, the caller, and who was notified.

CautionDo not hang up and report from memory. A misheard potassium value can lead to dangerous treatment errors.

## 핵심 개념

- **Critical value** — A laboratory result far outside the normal range that may be life-threatening and needs prompt reporting.
- **Read-back** — Repeating received information back to the sender so the sender can confirm it is correct.
- **Closed-loop communication** — An exchange in which the receiver confirms the message and the sender verifies it.
- **Hyperkalemia** — A high serum potassium that can cause muscle weakness and dangerous heart rhythms.

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