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 ["A","C","E"]

Explanation

Choice A reason: Orienting the client to their surroundings is essential for a confused patient. It can help reduce anxiety and prevent further confusion. It is a non-invasive, immediate intervention that can provide comfort and safety to the patient.

Choice B reason: Closing the client's room door is not recommended as it may increase the patient's feeling of isolation and can be a safety issue if the patient needs immediate assistance.

Choice C reason: Escorting the client back to the room is a correct action. It ensures the safety of the client by preventing falls or wandering, which could lead to harm.

Choice D reason: Raising all four side rails on the bed can be considered a form of restraint and is not recommended. It can increase the risk of injury if the client attempts to climb over the rails and can contribute to feelings of confusion and agitation.

Choice E reason: Securing a bed alarm on the mattress is a correct action. It alerts the staff if the client attempts to leave the bed, allowing for quick intervention to ensure the client's safety.

A. Review the client's medical history and admission assessment. B. Compare the client's current vital signs to the admission baseline. C. Note how frequently doses of analgesics have been administered. D. Ask the client to describe the intensity of the pain being experienced.

Correct Answer is D

Explanation

Choice A reason: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.

Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.

Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.

Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

Correct Answer is D

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)