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 ["A","B","C","D"]

Explanation

A. Recovery phase: The recovery phase occurs after the oliguric phase and is characterized by the gradual improvement of renal function. During this phase, diuresis may occur as the kidneys begin to excrete waste and excess fluid more effectively.

B. Diuretic phase: The diuretic phase follows the oliguric phase and is characterized by increased urine output as the kidneys start to recover and regain their ability to concentrate urine. This phase can lead to electrolyte imbalances and dehydration if not managed properly.

C. Initiation phase: The initiation phase marks the onset of acute renal failure and is characterized by the initial insult or injury to the kidneys. This phase may be triggered by various factors such as hypotension, nephrotoxic medications, or sepsis.

D. Oliguric phase: The oliguric phase is the initial phase of acute renal failure and is characterized by decreased urine output (<400 mL/day). During this phase, waste products and electrolytes may accumulate in the body, leading to metabolic acidosis and fluid overload.

A. Irregular pulsations B. Bounding pulsations C. Tachycardia D. Bradycardia

Correct Answer is A

Explanation

A. Irregular pulsations: Premature ventricular contractions (PVCs) are abnormal heartbeats originating in the ventricles, causing irregularities in the heart rhythm. Auscultating the apical pulse during PVCs may reveal irregular pulsations due to the irregular timing of ventricular contractions.

B. Bounding pulsations: Bounding pulsations are typically associated with conditions such as hypertension or aortic valve regurgitation but are not specifically characteristic of PVCs.

C. Tachycardia: PVCs may occur in the setting of tachycardia, but the presence of PVCs themselves does not necessarily indicate a rapid heart rate. The rhythm may be irregular due to PVCs, but the overall heart rate may not be consistently elevated.

D. Bradycardia: PVCs are not typically associated with bradycardia. Bradycardia refers to a slow heart rate, while PVCs involve premature extra beats originating from the ventricles.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client diagnosed with acute renal failure about how the disease progresses. The nurse should recognize that the teaching is effective when the client can accurately identify which phases of renal disease progression? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

Correct Answer is A

Explanation

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