After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

A. Assess strength of deep tendon reflexes:

Hyperkalemia can affect neuromuscular function, leading to alterations in deep tendon reflexes. However, determining the apical pulse rate and rhythm is more crucial as hyperkalemia can cause cardiac dysrhythmias and cardiac arrest.

B. Determine apical pulse rate and rhythm:

This is the most important intervention because hyperkalemia can lead to life-threatening cardiac dysrhythmias, including ventricular tachycardia and ventricular fibrillation. Monitoring the apical pulse rate and rhythm allows the nurse to detect any abnormalities promptly.

C. Compare muscle strength bilaterally:

Hyperkalemia can cause muscle weakness or paralysis due to its effects on neuromuscular function. While assessing muscle strength is important, monitoring cardiac function takes precedence because of the potential for life-threatening dysrhythmias.

D. Observe color and amount of urine:

Hyperkalemia can affect renal function, leading to changes in urine output and composition. While monitoring urine output and characteristics is important for assessing renal function, it is not the most critical intervention when managing acute hyperkalemia and its potential cardiac effects.

A. "This unit has a policy against staff harassment."

This response addresses the client's cursing behavior directly and attempts to establish boundaries by referring to the unit's policy. However, it may come across as confrontational and could potentially escalate the situation further. While it's important to address inappropriate behavior, in this case, responding with empathy and understanding might be more effective in de-escalating the situation and building rapport.

B. "It is important to dress the right arm first."

This response focuses on the physical aspect of dressing and does not acknowledge the client's frustration or emotional state. While it provides guidance on dressing technique, it does not address the underlying issue of the client's struggle or emotional distress. In this situation, addressing the client's emotional needs and frustrations may be more beneficial.

C. "Dressing must be a frustrating experience for you."

This response demonstrates empathy and understanding towards the client's frustration. It acknowledges the client's emotional state and validates their feelings, which can help build rapport and trust. By expressing empathy, the nurse can create a supportive environment and open the door for effective communication with the client.

D. "We will give you a class on dressing tomorrow."

This response offers a solution for the future but does not address the client's immediate frustration or emotional distress. While education on dressing techniques may be helpful in the long run, it does not address the client's current struggle or provide support in the moment. In this situation, addressing the client's emotional needs and frustrations should take priority.