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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: While medication shortages can occur, this is not the typical reason for delivering a partial supply of medication for home health care.

Choice B reason: Daptomycin is an antibiotic that has a limited shelf life after it is mixed or reconstituted. This is why pharmacies often deliver only a portion of the doses to ensure the medication remains effective.

Choice C reason: Notifying the healthcare provider is necessary if there is a discrepancy in medication delivery that cannot be explained by standard pharmacy practices.

Choice D reason: Although instructions for medication administration may change, this is not the usual reason for a pharmacy to deliver a partial supply of medication.

A. Modify the nursing interventions to achieve the client's goals. B. Determine if the expected outcomes were realistic. C. Obtain current client data to compare with expected outcomes. D. Review related professional standards of care.

Correct Answer is C

Explanation

Choice A reason: Modifying nursing interventions is a step that may be necessary after evaluating the effectiveness of care, but it is not the immediate next action after reviewing the expected outcomes.

Choice B reason: Determining if the expected outcomes were realistic is part of the evaluation process, but it requires current data to make an informed decision.

Choice C reason: Obtaining current client data is essential to compare with the expected outcomes and determine if the goals of care are being met.

Choice D reason: Reviewing related professional standards of care is important for ensuring quality care, but it is not the direct next step in evaluating the effectiveness of the client's nursing care.

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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)

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

Correct Answer is C

Explanation

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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)