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 C
Explanation
Excessive exposure to UV light, such as sunlight or tanning beds, is a known trigger for SLE exacerbations. It is important for individuals with SLE to protect their skin from the sun by wearing protective clothing, using sunscreen, and avoiding direct sunlight during peak hours. Having a family history of SLE increases the risk of developing the disease. While it is not a trigger in itself, it is an important piece of information for the client to be aware of, as it may indicate a genetic predisposition to the condition.
Acetaminophen is a commonly used over-the-counter pain reliever. While it can help manage pain associated with SLE, it is not typically considered a trigger for exacerbations. Menopause, which marks the end of a woman's reproductive years, does not directly trigger SLE exacerbations. However, hormonal changes during menopause can potentially affect disease activity in some individuals. It is important for the client to discuss any changes or concerns with their healthcare provider to manage their symptoms effectively.

Correct Answer is A
Explanation
Albuterol is a short-acting beta-agonist bronchodilator that provides rapid relief of bronchospasm and helps to alleviate the symptoms of respiratory distress in asthma. It acts quickly to relax the smooth muscles in the airways, improving airflow and relieving wheezing, coughing, and shortness of breath. In an acute asthma exacerbation, albuterol is often the first-line medication used to provide immediate relief and improve respiratory function. Prednisone is an oral corticosteroid that has anti-inflammatory effects and is commonly used in the treatment of asthma. However, it is typically administered orally and takes time to exert its effects. In the emergency department setting, the focus is on providing immediate relief of symptoms, and oral medications like prednisone may not have an immediate effect. Ipratropium is an anticholinergic bronchodilator that can be administered via inhalation. While it is effective in relieving bronchospasm, it is generally used as an adjunct to albuterol and not typically the first-line medication for severe respiratory distress in asthma. Fluticasone is an inhaled corticosteroid that has anti-inflammatory effects and is used for long-term management and control of asthma. It is not appropriate for immediate relief of severe respiratory distress and is not typically used as a first-line medication in the emergency department.
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