When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?
Reference Range:
Potassium (K+) 3.5 to 5 mEq/L (3.5 to 5 mmol/L)
Observe color and amount of urine.
Determine apical pulse rate and rhythm.
Compare muscle strength bilaterally.
Assess strength of deep tendon reflexes.
The Correct Answer is B
Choice A reason: Observing the color and amount of urine is important for assessing kidney function and hydration status but is not the most critical intervention for hypokalemia, which can have immediate life-threatening cardiac effects.
Choice B reason: Determining the apical pulse rate and rhythm is the most important intervention. Hypokalemia can lead to serious cardiac arrhythmias, and the apical pulse is the most accurate non-invasive way to assess cardiac rhythm and rate.
Choice C reason: Comparing muscle strength bilaterally is important for assessing the impact of hypokalemia on muscle function, but it is not as immediately life-threatening as cardiac effects.
Choice D reason: Assessing the strength of deep tendon reflexes can help evaluate neuromuscular involvement in hypokalemia but is less critical than monitoring for cardiac arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Excessive pressure can occlude arterial flow, preventing detection of the dorsalis pedis pulse. Reducing pressure allows blood flow to be felt, improving accuracy of pulse assessment.
Choice B rationale: Documentation without rechecking risks inaccurate reporting. Pulses may be present but obscured by technique, so confirming with proper palpation or alternative methods is necessary before recording findings.
Choice C rationale: Doppler stethoscope is useful but should be considered after correcting palpation technique. Initial step is adjusting pressure, as improper technique commonly explains absent pulse detection.
Choice D rationale: Palpating posterior tibial pulse assesses a different artery. While useful for circulation evaluation, it does not address the immediate issue of dorsalis pedis pulse palpation technique.
Correct Answer is B
Explanation
Choice A reason: Observing the color and amount of urine is important for assessing kidney function and hydration status but is not the most critical intervention for hypokalemia, which can have immediate life-threatening cardiac effects.
Choice B reason: Determining the apical pulse rate and rhythm is the most important intervention. Hypokalemia can lead to serious cardiac arrhythmias, and the apical pulse is the most accurate non-invasive way to assess cardiac rhythm and rate.
Choice C reason: Comparing muscle strength bilaterally is important for assessing the impact of hypokalemia on muscle function, but it is not as immediately life-threatening as cardiac effects.
Choice D reason: Assessing the strength of deep tendon reflexes can help evaluate neuromuscular involvement in hypokalemia but is less critical than monitoring for cardiac arrhythmias.
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