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A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

Suggest that the client use a salt substitute.

Advise the client to add citrus juices and bananas to her diet.

Obtain a 12-lead ECG

Obtain a blood sample for a serum sodium level

Answer and Explanation

The Correct Answer is C

Rationale:

A. Salt substitutes often contain potassium and should be avoided in clients with hyperkalemia.

B. Citrus juices and bananas are high in potassium and should be avoided in clients with hyperkalemia.

C. A 12-lead ECG may include changes such as peaked T wave, flattened P wave, prolonged PR interval, ST depression, and prolonged QRS duration.

D. A serum sodium level should be obtained but it is not the priority in this case.

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Correct Answer is D

Explanation

Rationale:

A. Synchronized cardioversion is not appropriate for pulseless ventricular tachycardia.

B. A repeat ECG is not necessary for pulseless ventricular tachycardia.

C. Assessment of blood pressure is not the priority in pulseless ventricular tachycardia.

D. Immediate defibrillation is the priority in pulseless ventricular tachycardia to restore a perfusing rhythm.

A. Murmur B. S3 and S4 C. Click D. Friction rub

Correct Answer is A

Explanation

Rationale:

A. Mitral valve regurgitation typically presents with a murmur, which is a characteristic sound associated with the backflow of blood into the left atrium during systole.

B. S3 and S4 are not typical heart sounds and do not relate to mitral valve regurgitation.

C. A click is typically associated with mitral valve prolapse, not mitral valve regurgitation.

D. A friction rub is typically associated with pericarditis, not mitral valve regurgitation.

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A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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