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 D

Explanation

A. "I get chest pain from time to time, but it usually resolves with rest.": While chest pain (angina) can occur with aortic stenosis, it is not as specific as the symptom described in option D. Angina could be related to various other cardiac conditions, including coronary artery disease.

B. "Sometimes when I'm resting, I can feel my heart skip a beat.": Palpitations or feeling like the heart skips a beat are common in many cardiac arrhythmias but are not specifically indicative of aortic stenosis.

C. "My feet and ankles have gotten very puffy the last few weeks.": Edema (puffy feet and ankles) is more commonly associated with right-sided heart failure or other conditions like chronic venous insufficiency, not specifically aortic stenosis.

D. "Whenever I do any form of exercise, I get very short of breath.": Dyspnea on exertion is a classic symptom of aortic stenosis. It occurs because the narrowed aortic valve obstructs blood flow from the left ventricle to the aorta, reducing cardiac output and causing exertional symptoms.

A. Dyspnea B. Malaise C. Fever D. Anorexia

Correct Answer is A

Explanation

A. Dyspnea: Worsening dyspnea may indicate complications such as heart failure or embolization of infectious material to the lungs, which can occur in infective endocarditis as a result of vegetation formation on heart valves. Dyspnea can suggest decreased cardiac output or pulmonary involvement, indicating a worsening condition.

B. Malaise: Malaise is a nonspecific symptom that is common in infective endocarditis due to systemic infection and inflammation. While it can be present in both mild and severe cases, it may not specifically indicate worsening of the condition without other signs of deterioration.

C. Fever: Fever is a hallmark symptom of infective endocarditis and may persist or worsen with progressive infection. However, fever alone may not necessarily indicate worsening if the client is already febrile due to the underlying infection.

D. Anorexia: Anorexia or loss of appetite can occur in infective endocarditis due to systemic illness but may not specifically indicate worsening without other signs of deterioration. It is important to assess for other signs of worsening condition, such as hemodynamic instability or embolic events, in conjunction with anorexia.

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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

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