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 (client care): A client reporting shortness of breath may be experiencing a life-threatening situation that aligns with the ABCs (Airway, Breathing, Circulation) of patient prioritization. This client requires immediate assessment and intervention.
Choice B reason (client care): While discharge is important, it does not take precedence over a client with potential respiratory distress.
Choice C reason (client care): A client who received pain medication 30 minutes ago is likely stable and can be seen after more urgent cases are addressed.
Choice D reason (client care): A client waiting for an abdominal x-ray is not a priority over a client with respiratory issues.
Correct Answer is C
Explanation
Choice A reason: Lactated Ringer's solution does not provide the necessary glucose and may not be compatible with TPN.
Choice B reason: 0.45% sodium chloride (0.45% NaCl) is a hypotonic solution and does not provide adequate calories for a patient on TPN.
Choice C reason: 10% dextrose in water (D10W) is the appropriate choice as it provides a source of calories and prevents hypoglycemia until the next TPN bag is available.
Choice D reason: 5% dextrose in lactated Ringer's solution (D5LR) provides less dextrose than D10W and may not prevent hypoglycemia as effectively.
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