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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.
Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.
Correct Answer is D
Explanation
Choice A rationale
While it’s true that phantom limb pain can be a normal post-surgical sensation, simply reassuring the patient doesn’t address the pain they’re experiencing.
Choice B rationale
Guiding in moving the unaffected limb to override the sensation being experienced is not a recommended intervention for phantom limb pain. Phantom limb pain is a complex phenomenon that is not simply overridden by movement of other body parts.
Choice C rationale
Explaining that the sensations of tingling and pain are not real may invalidate the patient’s experience. Phantom limb pain is a real phenomenon experienced by many amputees. It’s not just a sensation; it’s a type of neuropathic pain that can be severe and debilitating.
Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is the best non-pharmacological intervention among the choices. Physical therapy, including mirror therapy and other desensitization techniques, can help manage phantom limb pain. The use of a prosthetic can help the patient regain function and mobility, which can also improve their overall well-being and potentially reduce the perception of phantom limb pain.
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