A patient with a history of heart failure presents at the emergency department reporting fatigue and weakness. The patient has been taking 50 mg spironolactone tablets orally every day.

The nurse receives a lab report indicating the patient’s serum potassium level is 6.2 mEq/L (6.2 mmol/L). What is the most important intervention for the nurse to implement?

Compare muscle strength bilaterally.

Observe the color and amount of urine.

Determine the apical pulse rate and rhythm.

Assess the strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Comparing muscle strength bilaterally is not the most important intervention in this situation. While muscle weakness can be a symptom of hyperkalemia, it is not the most immediate concern. Hyperkalemia can lead to life-threatening cardiac dysrhythmias, which is a more immediate threat to the patient’s life.

Choice B rationale

Observing the color and amount of urine can provide information about the patient’s renal function, which is important in the regulation of potassium. However, this is not the most immediate concern when a patient’s serum potassium level is dangerously high.

Choice C rationale
Determining the apical pulse rate and rhythm is the most important intervention. Hyperkalemia can cause cardiac dysrhythmias, so the nurse should immediately assess the patient’s heart rate and rhythm. The nurse should also place the patient on a cardiac monitor, if not already done, and notify the healthcare provider immediately.

Choice D rationale
Assessing the strength of deep tendon reflexes can provide information about neuromuscular function, which can be affected by hyperkalemia. However, this is not the most immediate concern. The nurse’s priority is to assess and monitor for life-threatening cardiac dysrhythmias.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale
Oxygen therapy is a crucial part of the management for patients with severe pneumonia. However, prolonged administration of high concentrations of oxygen can potentially lead to oxygen toxicity, resulting in damage to the cells of the lungs. This is due to the production of

reactive oxygen species which can damage cell structures. Therefore, it is important to avoid administering oxygen at high levels for extended periods.
Choice B rationale
While it might seem logical to increase the oxygen rate during sleep due to a slower respiratory rate, this is not typically recommended. The body’s oxygen requirements do not significantly change during sleep and increasing the oxygen rate could potentially lead to hyperoxia.
Choice C rationale
Sedatives can indeed slow the respiratory rate, but this does not decrease oxygen needs. In fact, it could potentially lead to respiratory depression and hypoxia, especially in a patient with a respiratory illness like pneumonia.
Choice D rationale
Humidification of oxygen can improve patient comfort, especially with high flow rates, by preventing dryness in the nasal passages. However, it does not make oxygen less toxic.

A. Utilize an electric heating pad when the pain is at its worst. B. Refrain from taking medications containing acetylsalicylic acid. C. Consume high protein foods to achieve ideal body weight. D. Encourage active range of motion to limit stiffness.

Correct Answer is B

Explanation

Choice A rationale
Using an electric heating pad when the pain is at its worst is not recommended for a client with gout. Heat can increase inflammation and exacerbate pain. Instead, applying a cold pack to the inflamed joint can help reduce inflammation and relieve pain.
Choice B rationale
Acetylsalicylic acid, also known as aspirin, can increase uric acid levels in the blood and exacerbate gout symptoms. Therefore, clients with gout should avoid taking medications containing acetylsalicylic acid.
Choice C rationale
Consuming high-protein foods can increase uric acid levels in the blood and trigger a gout attack. Clients with gout are usually advised to follow a low-purine diet, which involves limiting the intake of high-purine foods such as red meat and seafood.

Choice D rationale
Encouraging active range of motion to limit stiffness may not be appropriate for a client with an acute gout attack. During an attack, moving the affected joint can be extremely painful. Rest and immobilization of the affected joint are usually recommended during this time.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula. When planning care for this child, what principle of oxygen administration should the nurse keep in mind?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

Mark whether the statements by the new graduate nurse indicate understanding or no understanding of the use of the face mask in the care of this client.

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What interventions should the nurse include in this client’s plan of care? Select all that apply.

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?

An adolescent patient with a non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. After the healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg, what should the nurse do next?

A caregiver brings a client with end-stage Alzheimer’s disease to the clinic for an appointment with the healthcare provider. The caregiver confides in the nurse about experiencing sleepless nights and frequent bouts of crying. What action should the nurse take?

The nurse is preparing a dose of teriparatide for a patient. The medication is labeled as “750 mcg/2.4 mL”. How many mL should the nurse administer to deliver a dose of 60 mcg