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 D
Explanation
Choice A reason: Aspirin can irritate the stomach lining and increase acid reflux, worsening GERD symptoms. It is generally not recommended without consulting a healthcare provider.
Choice B reason : Mercury content in seafood is not directly linked to GERD. This statement is misleading and does not address known risk factors for GERD.
Choice C reason : Lying down after eating can indeed increase the onset of GERD as it allows stomach contents to flow back into the esophagus more easily.
Choice D reason : Alcohol and caffeine can relax the lower esophageal sphincter, allowing stomach acid to rise into the esophagus and worsen GERD symptoms. Therefore, it is advisable to avoid or reduce their intake.
Correct Answer is D
Explanation
Choice A reason: Avoiding tanning booths is correct and does not indicate a need for further teaching.
Choice B reason: Using sunscreen even on cloudy days is correct and does not indicate a need for further teaching.
Choice C reason: Checking the skin monthly for any changes is correct and does not indicate a need for further teaching.
Choice D reason: The statement about eating a high-fiber diet reducing the risk for developing skin cancer indicates a misunderstanding, as there is no direct correlation between a high-fiber diet and the prevention of skin cancer. This indicates a need for further teaching.
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