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","D","E","F","G","H","J"]
Explanation
● Weight 98 lbs: This information helps determine the patient's baseline weight and assess for potential weight loss associated with dehydration.
● Dehydrated: The diagnosis of dehydration indicates a critical condition that requires immediate attention and intervention.
● Lethargy: Lethargy suggests a decreased level of consciousness and could indicate a severe state of dehydration or other underlying issues that need to be addressed promptly.
● HR 122: A heart rate of 122 beats per minute is elevated and may indicate compensatory mechanisms in response to dehydration or other underlying conditions. It requires further evaluation and intervention.
● Shortness of Breath: This symptom suggests respiratory distress and may be related to the patient's dehydration or underlying conditions. It requires immediate assessment and intervention.
● Temperature 100: An elevated temperature may indicate an underlying infection or inflammatory response. It requires further evaluation to determine the cause and guide appropriate treatment.
● Thirsty: The patient's report of feeling thirsty is an important symptom indicating dehydration and the need for fluid replacement.
● BP 90/50: A blood pressure of 90/50 is low and may be indicative of hypotension, which can occur in dehydration. It requires close monitoring and intervention to stabilize the patient's blood pressure.
The following items are not immediate concerns based on the given information: ● Admitted to the ER: While it is important information, it is not a current concern as the patient is already in the ER.
● Female: The patient's gender is not an immediate concern for the assessment and management of dehydration.
Correct Answer is D
Explanation
To calculate the patient's body mass index (BMI), we need to divide the weight (in kilograms) by the square of the height (in meters). Let's convert the height and weight measurements to the appropriate units and perform the calculation:
Height: 5 feet, 6 inches = 5 + (6/12) = 5.5 feet = 1.6764 meters (rounded to four decimal places) Weight: 250 lb. = 113.3 kg
BMI = Weight (kg) / (Height (m))^2
BMI = 113.3 kg / (1.6764 m)^2
BMI ≈ 40.0
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