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 C
Explanation
Choice A reason: A negative urine dipstick for nitrites is more indicative of a lack of bacterial infection and is not directly related to glomerulonephritis.
Choice B reason: While the absence of pain or burning with voiding is positive, it does not specifically indicate the resolution of glomerulonephritis.
Choice C reason: The resolution of periorbital and peripheral edema is a sign that the treatment for glomerulonephritis has been effective, as edema is a common symptom of this condition.
Choice D reason: A decrease in the anti-streptolysin-O (ASO) titer may indicate a response to treatment for a streptococcal infection, but it is not the most direct indicator of effective treatment for glomerulonephritis.
Correct Answer is C
Explanation
Choice A reason: While disturbed body image is a concern, it is not the highest priority for a patient undergoing a bone marrow transplant.
Choice B reason: Anxiety is important to address but does not take precedence over physical health concerns in the immediate post-transplant period.
Choice C reason: Ineffective protection is the highest priority because patients undergoing bone marrow transplants have compromised immune systems and are at high risk for infection.
Choice D reason: Imbalanced nutrition is a concern but is secondary to the risk of infection in the immediate care of a patient post bone marrow transplant.
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