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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. The client has circumoral cyanosis: Circumoral cyanosis, or bluish discoloration around the mouth, is a sign of hypoxia but may not be present in all cases of hypoxemia. Pulse oximetry provides a more objective measurement.

B. The client's heart rate is 86 bpm: Heart rate may be within normal limits even in the presence of hypoxemia, as compensatory mechanisms may not be fully activated.

C. The client has a pulse ox of 90% on room air: A pulse oximetry reading of 90% indicates hypoxemia (oxygen saturation below normal levels), which is a significant finding, especially in a client with COPD who may already have compromised respiratory function.

D. The client is lethargic: Lethargy may occur with severe hypoxemia, but it is a late sign and may not always be present. Monitoring oxygen saturation is more reliable for early detection of hypoxemia.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

Pneumocystis pneumonia (PCP) is a common opportunistic infection in individuals with AIDS, particularly when their CD4 T-cell count falls below 200/mm3. PCP is caused by the fungus Pneumocystis jirovecii and is a significant cause of morbidity and mortality in AIDS patients. The CD4 T-cell count is a key indicator of immune function in HIV/AIDS patients. A CD4 T-cell count below 200/mm3 is indicative of severe immune suppression and significantly increases the risk of opportunistic infections such as pneumocystis pneumonia.

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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?

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