A client with a history of heart failure arrives at the emergency department describing an onset of fatigue and weakness.

The client has been taking spironolactone 50 mg tablets PO every day.

The nurse receives a report from the lab that the client has a serum potassium level of 6.2 mEq/L (6.2 mmol/L). Which intervention is most important for the nurse to implement?

Compare muscle strength bilaterally.

Observe color and amount of urine.

Determine apical pulse rate and rhythm.

Assess strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Comparing muscle strength bilaterally is important in assessing overall physical health and detecting any potential neuromuscular disorders. However, in the context of a client with a history of heart failure and elevated potassium levels, this would not be the most critical intervention. High potassium levels can lead to hyperkalemia, which can cause serious heart rhythm disturbances.
Choice B rationale
Observing the color and amount of urine can provide valuable information about the client’s hydration status and kidney function. In the case of heart failure, monitoring urine output can help assess the effectiveness of diuretic therapy and the progression of the disease. However, it is not the most immediate concern given the client’s high potassium levels.
Choice C rationale

Determining the apical pulse rate and rhythm is the most important intervention in this scenario. A serum potassium level of 6.2 mEq/L is higher than the normal range (3.5-5.0 mEq/L) and can cause life-threatening heart rhythm abnormalities. Therefore, the nurse should prioritize assessing the client’s heart rhythm to detect any abnormalities caused by this electrolyte imbalance.
Choice D rationale
Assessing the strength of deep tendon reflexes can help identify changes in neuromuscular function and is often used in neurological assessments. However, it is not the most critical intervention in the context of elevated potassium levels and heart failure.

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Free Nursing Study Resources

Correct Answer is ["1.80"]

Explanation

Step 1 is to convert the patient’s weight from pounds to kilograms since the dosage is prescribed in mg/kg. We know that 1 kg is approximately 2.20462 pounds. So, the patient’s weight in kilograms is 132 pounds ÷ 2.20462 = 59.87 kg.

Step 2 is to calculate the total dosage of dantrolene needed. The prescribed dosage is 1.5 mg/kg. So, the total dosage is 1.5 mg/kg × 59.87 kg = 89.81 mg.

Step 3 is to calculate the volume of reconstituted dantrolene solution needed to provide the total dosage. The reconstituted solution has a concentration of 50 mg/mL. So, the volume needed is 89.81 mg ÷ 50 mg/mL = 1.80 mL.

A. Allowing the client to express their feelings. B. Wearing gloves during the client interview. C. Offering a handshake during introductions. D. Encouraging the client to join a support group.

Correct Answer is C

Explanation

Choice A rationale
Allowing the client to express their feelings is an important part of providing psychosocial support. However, it does not specifically address the client’s need for acceptance.
Choice B rationale

Wearing gloves during the client interview can actually reinforce feelings of stigma and rejection, as it may suggest that the nurse is afraid of touching the client or catching their condition.
Choice C rationale
Offering a handshake during introductions can be a powerful gesture of acceptance, especially for a client with a visible skin condition like psoriasis. It communicates that the nurse is not afraid of physical contact and accepts the client as they are.
Choice D rationale
Encouraging the client to join a support group can provide them with a sense of community and shared experience, but it does not specifically address the client’s need for acceptance in their individual interactions with healthcare providers.

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Naxlex Comprehensive Predictor Exams

A patient with neuroleptic malignant syndrome has been prescribed dantrolene 1.5 mg/kg IV. The patient weighs 132 pounds. The label on the 250 mg vial reads, “Reconstitute with 5 mL sterile water for injection, USP. Reconstitution yields 50 mg/mL.”. How many mL should the nurse administer?

Correct Answer is ["1.80"]

Explanation

In the context of caring for a client diagnosed with psoriasis, which action by the nurse would address the client’s psychosocial need for acceptance?

Correct Answer is C

Explanation

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?

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The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility. Which outcome statement should the nurse include in the plan of care?

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