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 D
Explanation
Mrs. Kalen is diagnosed with gastroenteritis and dehydration, and the arterial blood gas results indicate metabolic alkalosis (elevated pH and HCO3-). This suggests that there is an excessive loss of gastric acid and chloride ions from vomiting, leading to an imbalance of electrolytes and an increase in bicarbonate levels.
To correct the imbalance and treat dehydration, the primary intervention is fluid replacement. Administration of IV 0.9 Saline Solution, also known as normal saline, is commonly used for fluid resuscitation and rehydration. This isotonic solution helps restore fluid balance and electrolyte levels in the body.
Administration of antiemetics may help control vomiting, but the primary treatment focus in this case is fluid and electrolyte replacement to correct dehydration and the associated metabolic alkalosis.
Administration of diuretics, which increase urine output, would not be appropriate in this case as the patient is already experiencing dehydration.
Electrolyte replacement may be necessary if there are specific electrolyte imbalances identified, but the primary treatment is fluid replacement with IV saline solution.
Having the patient go home and rest without addressing the underlying dehydration and metabolic alkalosis would not be appropriate as it can lead to further complications.
Correct Answer is A
Explanation
Kawasaki disease is an inflammatory condition that primarily affects children, causing symptoms such as fever, rash, conjunctivitis, swollen lymph nodes, and changes in the hands and feet, including skin peeling. It is important to create a calm and quiet environment for the child to minimize stimulation and discomfort.
Placing the child in a quiet environment helps reduce irritability and allows the child to rest. It also helps prevent further stress and agitation, which can exacerbate the symptoms of
Kawasaki disease. Providing a quiet space can promote comfort and improve the child's overall well-being.
Applying lotion to the hands and feet may be beneficial for soothing any dry or peeling skin, but it is not the priority intervention. Creating a quiet environment to address the child's irritability and discomfort takes precedence.
Encouraging the parents to rest when possible and making a list of foods that the child likes are important aspects of care, but they are not the immediate interventions to address the child's current symptoms of irritability, refusal to eat, and skin peeling. These interventions can be addressed after providing a quiet environment and ensuring the child's comfort.
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