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A nurse is assessing a patient with hypokalemia, she notes that the patient's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?

A.

Assess the patient’s respiratory rate, rhythm, depth

B.

Call the healthcare provider

C.

Document findings and monitor the patient

D.

Measure the patient’s pulse and blood pressure

Answer and Explanation

The Correct Answer is A

A. Assess the patient’s respiratory rate, rhythm, depth:

This is the correct action to take first. Hypokalemia can lead to respiratory muscle weakness, which can result in respiratory compromise or failure. Assessing the patient's respiratory rate, rhythm, and depth will help determine if there are any signs of respiratory distress or impending respiratory failure.

B. Call the healthcare provider:

While it's important to involve the healthcare provider, especially if there is a significant change in the patient's condition, assessing the patient's immediate respiratory status takes priority to ensure prompt intervention if respiratory distress is present.

C. Document findings and monitor the patient:

Documenting findings and ongoing monitoring are essential steps, but they come after addressing the patient's immediate needs, such as assessing respiratory status in this case.

D. Measure the patient’s pulse and blood pressure:

While vital signs are important, they may not immediately address the potential respiratory compromise associated with hypokalemia-induced muscle weakness. Assessing respiratory status is more directly relevant to the observed change in handgrip strength.


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Related Questions

Correct Answer is ["A","B","C","D"]

Explanation

  1. A. Measure the depth and width of the wound. Regular assessment and documentation of the wound’s size can help track the progress of healing and effectiveness of the treatment plan.

    B. Educate the client about the need for antibiotics. If an infection is present, antibiotics may be necessary. It’s important for the client to understand the purpose and proper use of these medications.

    C. Consult a nutritionist for a diet plan. Good nutrition is essential for wound healing. Certain nutrients, like protein, vitamin C, and zinc, can promote wound healing.

    D. Remove any non-viable tissue. Debridement, or the removal of dead (non-viable) tissue, can help promote the healing of the wound by reducing the risk of infection and allowing healthy tissue to grow.

Correct Answer is B

Explanation

  1. A. How many people live in your home?

    This question pertains to social and environmental factors but is not directly related to assessing skin inflammation on the chest. While social factors can impact overall health, such as stress levels or exposure to infectious agents, the number of people living in the client's home is unlikely to be directly related to a new skin inflammation unless there are specific circumstances, such as sharing personal care products or close contact with others who have similar skin issues.

    B. Did you have a recent exposure to irritants?

    This question is highly relevant to assessing a new skin inflammation on the chest. Exposure to irritants or allergens can trigger or worsen skin conditions, such as contact dermatitis or allergic reactions. By asking about recent exposure to potential irritants like new detergents, soaps, fabrics, chemicals, or environmental factors, the nurse can gather important information to identify possible triggers for the skin inflammation.

    C. Is nausea associated with your rash?

    Nausea is typically not directly associated with a skin rash or inflammation unless there is a systemic condition or allergic reaction causing both symptoms. While it's important to assess for any systemic signs or symptoms that may be related to the skin condition, such as fever or malaise, specifically asking about nausea may not provide relevant information about the skin inflammation on the chest.

    D. What is your body mass index?

    Body mass index (BMI) is a measure of body weight relative to height and is not directly related to assessing a new skin inflammation on the chest. While obesity or changes in body weight can sometimes contribute to skin issues, such as friction-related dermatitis or hormonal changes affecting skin health, BMI alone is not a primary assessment parameter for localized skin conditions unless there are specific concerns related to weight-related skin problems.

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