A client diagnosed with End Stage Renal Disease (ESRD) has a potassium level of 6.8 mEq/L. Which of the following priority actions should the nurse implement?
Instruct the client to avoid high-potassium foods.
Redraw the potassium to verify results.
Check the client's blood pressure.
Obtain a serum sodium level.
The Correct Answer is C
A. Instruct the client to avoid high-potassium foods: While important for long-term management, it is not the priority when the client is experiencing hyperkalemia, as immediate interventions are necessary to prevent complications.
B. Redraw the potassium to verify results: Redrawing the potassium may be necessary if there is concern about sample contamination or if the result is significantly different from what is expected. However, it is not the priority when the client is at risk of complications from hyperkalemia.
C. Check the client's blood pressure: This is the priority action because hyperkalemia can lead to cardiac dysrhythmias, including potentially life-threatening arrhythmias. Checking the blood pressure helps assess the client's cardiovascular status and any potential effects of hyperkalemia on cardiac function.
D. Obtain a serum sodium level: While monitoring electrolyte levels is important in ESRD, sodium levels are not the priority when the client is experiencing hyperkalemia. Monitoring potassium and managing its effects take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Obtain pulse oximetry every two hours: While monitoring oxygen saturation is important in assessing respiratory status, it is not a direct intervention for preventing atelectasis. It is more of an assessment tool to evaluate the effectiveness of interventions aimed at preventing atelectasis.
B. Teach the client how to use the incentive spirometer: Incentive spirometry is a valuable tool for preventing atelectasis postoperatively by promoting deep breathing and lung expansion. Teaching the client how to use the incentive spirometer and encouraging its frequent use can help maintain lung volume and prevent collapse of alveoli.
C. Instruct the client to practice abdominal breathing: While abdominal breathing can be beneficial for promoting relaxation and reducing anxiety, it is not as effective as incentive spirometry in preventing atelectasis postoperatively.
D. Encourage oral fluid intake of 2000 mL/24 hours: Adequate hydration is important for overall health and respiratory function, but it is not specifically targeted at preventing atelectasis. While hydration can help maintain airway secretions thin, it is not the primary intervention for preventing atelectasis after a lobectomy.
Correct Answer is C
Explanation
A. Joint contractures: Joint contractures are a common manifestation of systemic scleroderma, but they are not directly related to altered tissue perfusion. They are more related to skin and tissue fibrosis.
B. Peripheral arterial dilation: Peripheral arterial dilation is not typically associated with systemic scleroderma. Instead, peripheral vasoconstriction, such as in Raynaud's phenomenon, is more common.
C. Raynaud's phenomenon: Raynaud's phenomenon, characterized by episodic vasospasm of small arteries in response to cold or stress, can lead to impaired tissue perfusion, especially in the extremities.
D. Pulmonary fibrosis: Pulmonary fibrosis is a complication of systemic scleroderma that affects lung tissue, but it is not directly related to altered tissue perfusion. It may lead to impaired gas exchange rather than altered perfusion.
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