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","B","C","E"]
Explanation
Choice A reason : Heart disease prevention is essential in managing pulmonary edema, especially when it is related to a cardiac condition.
Choice B reason : A healthy lifestyle, including diet and exercise, supports overall heart health and can help manage pulmonary edema.
Choice C reason : Smoking cessation is critical as smoking can exacerbate heart conditions and pulmonary edema.
Choice D reason : The goal of weight control is typically to reduce BMI, not increase it to over 35, which is considered obese.
Choice E reason : Glycemic control is important for diabetic patients to manage their condition and reduce the risk of complications, including pulmonary edema.
Correct Answer is C
Explanation
Choice A reason: While a stable ECG rhythm is important, it is not the immediate concern post-AMI.
Choice B reason: The ability to verbalize causes and effects of CHD/CAD is an educational goal, not an immediate care priority.
Choice C reason: Adequate relief of pain is a priority to reduce stress on the heart and improve patient comfort.
Choice D reason: Compliance with prescribed bedrest is important but secondary to pain relief.
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