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 ["B","C","E"]

Explanation

A. Lime: Lime can cause chemical burns, especially when in contact with moisture (e.g., skin or eyes), but it is less common than some other agents listed.

B. Hydrofluric acid: Hydrofluoric acid is highly corrosive and can cause severe burns upon contact with the skin or mucous membranes.

C. Bleach: Bleach, particularly sodium hypochlorite, is a common household chemical that can cause chemical burns, especially in concentrated forms.

D. Fabric softener: While fabric softeners contain chemicals, they are not typically known to cause significant chemical burns unless ingested or used improperly.

E. Gasoline: Gasoline is a flammable liquid that can cause chemical burns upon skin contact.

A. Isolation gown B. Contact isolation C. Standard precautions D. Respiratory isolation

Correct Answer is C

Explanation

A. Isolation gown: Isolation gowns are used as part of contact precautions or airborne precautions for specific infectious diseases that require additional transmission-based precautions beyond standard precautions. However, standard precautions are generally sufficient for caring for clients with HIV receiving antiretroviral therapy.

B. Contact isolation: Contact isolation is used for patients with known or suspected infections that can be transmitted by direct or indirect contact with the patient or their environment. HIV does not require contact isolation unless there are additional infections or conditions present that warrant contact precautions.
C. Standard precautions: Standard precautions are the basic infection prevention practices that apply to all patient care, regardless of the suspected or confirmed infection status of the patient. This includes practices such as hand hygiene, the use of personal protective equipment (e.g., gloves, gown, mask, eye protection) when indicated, and safe injection practices. Standard precautions should be used for all patients, including those with HIV, to prevent the transmission of infectious agents.
D. Respiratory isolation: Respiratory isolation is used for patients with known or suspected respiratory infections that are transmitted through respiratory droplets. HIV is not transmitted through respiratory droplets and does not require respiratory isolation.

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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 client is admitted to the burn unit with chemical burns. The nurse understands that which of the following agents are potential causes of the client's burn injuries? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is C

Explanation

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