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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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. Praise the UAP for using standard precautions. B. Instruct the UAP to change gloves immediately. C. Request that an in-service program be scheduled on asepsis. D. Submit an adverse occurrence report to the unit manager.

Correct Answer is B

Explanation

Choice A reason: Praising the UAP for using standard precautions is not appropriate in this situation as using the same gloves for multiple clients breaches infection control protocols.

Choice B reason: The nurse should instruct the UAP to change gloves immediately to prevent cross-contamination between clients.

Choice C reason: While scheduling an in-service program on asepsis is beneficial for long-term education, it does not address the immediate risk of infection.

Choice D reason: Submitting an adverse occurrence report may be necessary if there is a pattern of non-compliance, but the first action should be to correct the behavior and ensure client safety.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

Correct Answer is B

Explanation

The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?

The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

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)