In reviewing the electrolytes of a patient, the nurse notes the serum potassium level has increased from 4.3 mEq/L to 5.9 mEq/L. Which assessment does the nurse initiate first to prevent further harm?
Oxygen Stats
Pulse rate and Rhythm
Respiratory rate and depth
Deep tendon reflexes
The Correct Answer is B
An increased serum potassium level, also known as hyperkalemia, can have adverse effects on the electrical conduction of the heart, potentially leading to life-threatening cardiac dysrhythmias. Therefore, it is crucial to assess the patient's pulse rate and rhythm promptly to identify any abnormal cardiac activity.
Assessing the oxygen saturation (oxygen stats), respiratory rate and depth, and deep tendon reflexes are also important assessments, but they are not the priority in this case. Hyperkalemia primarily affects cardiac function, and prompt identification of any potential cardiac rhythm disturbances is essential to prevent further harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
a. Considered primary treatment for small cell lung cancer (SCLC): Chemotherapy b. Used to prevent metastasis to the brain: Prophylactic cranial radiation
c. Electric current heats and destroys tumor cells: Radiofrequency ablation d. Best procedure for cure of lung cancer: Surgery
e. Medications that block molecules involved in tumor: Biologic and targeted
Correct Answer is B
Explanation
Gentamicin is an antibiotic that is usually administered via IV infusion. The peak level is the highest concentration of the medication in the bloodstream, and it is important to monitor it to ensure therapeutic levels are achieved without reaching toxic levels.
Drawing the peak level 30 minutes after the infusion is complete allows enough time for the medication to distribute throughout the body and reach its peak concentration. This timing provides an accurate representation of the highest drug concentration in the bloodstream. 30 minutes before starting the infusion: Drawing the peak level before starting the infusion would not accurately reflect the peak concentration of the medication in the bloodstream. Immediately before the next dose of Gentamicin: Drawing the peak level immediately before the next dose would not provide an accurate assessment of the highest drug concentration, as the levels would have started to decrease due to elimination.
1 hour after infusion is complete: Waiting for 1 hour after the infusion is complete may result in missing the actual peak concentration of the medication in the bloodstream, as it may have already started to decline.
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