A client's serum potassium level is approaching 7 mEq/L. Which physical assessment would the nurse prioritize based on this serum lab value?

Cardiac

Gastrointestinal

Respiratory

Neurologic

Answer and Explanation

The Correct Answer is A

A. Hyperkalemia can have significant cardiac effects, potentially leading to life-threatening arrhythmias such as bradycardia, heart block, ventricular tachycardia, or ventricular fibrillation. As potassium levels rise, it affects the electrical conduction of the heart, leading to changes in the ECG (electrocardiogram) and potentially causing fatal arrhythmias.

B. While hyperkalemia primarily affects the cardiovascular system, gastrointestinal symptoms can also occur. These may include nausea, vomiting, abdominal pain, and diarrhea. However, these symptoms are typically less severe compared to cardiac manifestations. Monitoring for gastrointestinal symptoms helps in assessing overall clinical status but is not as critical as assessing cardiac function in the context of hyperkalemia.

C. Respiratory symptoms are not typically associated with hyperkalemia unless severe acid-base disturbances are present. Potassium imbalance itself does not directly affect respiratory function. Therefore, while it is important to assess respiratory status in any client, it is not the priority in the context of hyperkalemia.

D. Hyperkalemia can affect the nervous system, leading to symptoms such as muscle weakness, tingling sensations, and even paralysis in severe cases. However, neurologic symptoms usually occur at higher potassium levels or in the presence of significant electrolyte imbalances affecting nerve function.

Monitoring for neurologic symptoms is important but is generally secondary to assessing cardiac status in the context of approaching severe hyperkalemia.

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Correct Answer is B

Explanation

B. This is the initial phase of the nurse-client relationship where the individuals first meet. It is characterized by establishing rapport, clarifying roles, setting goals, and developing an agreement or contract for the relationship.

A. This phase occurs towards the end of the nurse-client relationship when goals have been achieved or the relationship is ending for other reasons. It involves summarizing, evaluating progress, and saying goodbye.

C. This phase follows the orientation phase. It is characterized by actively working together to achieve mutually agreed upon goals. During this phase, the nurse and client explore issues, develop and implement solutions, and evaluate progress towards goals.

D. This phase occurs before the nurse and client meet formally. It involves gathering information about the client from various sources, such as medical records or other healthcare professionals.

A. was negligent, resulting in harm to the client. B. was acting on the principle of nonmaleficence. C. committed a misdemeanor. D. was unethical in her practice.

Correct Answer is A

Explanation

A. Negligence in nursing refers to the failure to provide care that meets established standards, resulting in harm to the patient. In this case, if the nurse failed to monitor vital signs as per hospital policies and this failure led to complications for the post-operative client, it could constitute negligence. Negligence involves breaching the duty of care owed to the patient, causing harm that could have been reasonably prevented.

B. Nonmaleficence is the principle of doing no harm. While it is an ethical principle guiding healthcare practice, it does not justify or excuse negligence. Negligence involves a failure to uphold the duty of care owed to the patient, resulting in harm due to substandard practice.

C. A misdemeanor typically refers to a lesser criminal offense. Negligence in healthcare generally does not rise to the level of a criminal offense like a misdemeanor unless there is gross negligence or willful misconduct. In most cases, negligence leading to harm is addressed through civil litigation rather than criminal charges.

D. While negligence can certainly be considered unethical behavior in the context of healthcare, negligence itself is a legal concept related to professional malpractice rather than solely an ethical breach. Ethical violations may involve different aspects of professional conduct not directly related to negligence, such as breaches of confidentiality or conflicts of interest.

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A client's serum potassium level is approaching 7 mEq/L. Which physical assessment would the nurse prioritize based on this serum lab value?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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