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 B
Explanation
Choice A rationale
While regular monitoring of blood sugar levels is important in managing diabetes, checking every four to six hours every day may not be necessary for all patients. The frequency of blood glucose monitoring should be individualized based on the type and severity of the diabetes, the patient’s blood glucose control, and the patient’s specific needs.
Choice B rationale
Keeping diabetic medication on schedule as prescribed is crucial in managing blood glucose levels and preventing complications related to diabetes. This indicates that the patient has understood the importance of medication adherence in diabetes management.
Choice C rationale
While it’s recommended to limit alcohol consumption, restricting alcoholic beverages to no more than 1-2 per week is not a standard guideline for all patients with diabetes. The effects of alcohol on blood glucose levels can vary depending on several factors, including the amount of alcohol consumed, the presence of food, and the individual’s overall diabetes management.
Choice D rationale
Limiting daily fat intake to 15% of total calories is not a standard recommendation for patients with diabetes. The American Diabetes Association recommends individualized medical nutrition therapy to manage diabetes, which may include monitoring carbohydrate intake and considering the quality of fats and proteins in the diet.
Correct Answer is []
Explanation
Correct Actions:
Administer calcium as prescribed - Administering calcium (usually IV calcium gluconate) corrects the calcium deficiency, stabilizes nerve and muscle function, and helps stop or prevent further seizures.
Monitor respiratory status - Monitoring respiratory rate, effort, and oxygen saturation ensures early detection of hypoventilation, apnea, or oxygen desaturation.Maintaining airway and oxygenation is critical for safety and preventing hypoxia.
Correct Condition:
Hypocalcemia, or low calcium levels in the blood, can cause seizures in infants. Phenytoin, the medication given to the baby in the ambulance, is used to control seizures. Therefore, hypocalcemia could be the condition the infant is experiencing.
Correct Parameters to monitor:
Monitoring the respiratory rate is an important part of assessing any patient’s condition, especially an infant who has had a seizure.
Monitor serum calcium levels - Maintaining calcium within the normal neonatal range prevents recurrent seizures, cardiac arrhythmias, or neuromuscular irritability.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
