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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is ["A","B","C","D"]
Explanation
A. Give the client a low sodium diet: SIADH causes retention of water and dilutional hyponatremia. Therefore, restricting sodium intake can help prevent further fluid retention and worsening of hyponatremia.
B. Monitor for serum electrolyte imbalances: SIADH can lead to electrolyte imbalances, particularly hyponatremia. Monitoring electrolyte levels, especially sodium, is essential for early detection and intervention.
C. Obtain daily weights: Monitoring daily weights is crucial for assessing fluid balance and detecting changes in hydration status, which is essential in clients with SIADH.
D. Educate the client on techniques to cope with thirst: Clients with SIADH often experience excessive thirst due to the body's inability to excrete excess water. Educating the client on strategies to manage thirst, such as chewing gum or sucking on ice chips, can help improve comfort.
E. Increase IV fluids: This option is incorrect because SIADH is characterized by water retention, so increasing IV fluids would exacerbate the condition and worsen hyponatremia.
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