A male client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should nurse Olivia assess first?
Blood pressure
Temperature
Respirations
Pulse rate
The Correct Answer is D
Choice A reason: While blood pressure is important, hyperkalemia can cause cardiac dysrhythmias, making the pulse rate the first assessment to ensure the patient's immediate safety.
Choice B reason: Temperature is not directly affected by serum potassium levels and is not the priority in hyperkalemia.
Choice C reason: Respirations are less likely to be affected immediately by hyperkalemia compared to cardiac function.
Choice D reason: A high serum potassium level can lead to life-threatening cardiac arrhythmias, so assessing the pulse rate is the most critical initial action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hypertension is a well-known modifiable risk factor for stroke. Controlling blood pressure can significantly reduce the risk of having a stroke.
Choice B reason: A history of sickle cell disease is a genetic condition and is not considered a modifiable risk factor.
Choice C reason: Having a parent with cardiovascular disease is a non-modifiable risk factor as it is related to genetics.
Choice D reason: Age is a non-modifiable risk factor for stroke. The risk of stroke increases with age.
Correct Answer is C
Explanation
Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.
Choice B reason : Educating the patient about the causes and effects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.
Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.
Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.
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