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 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.
Correct Answer is ["D","E","F"]
Explanation
Choice A reason:
Exercising in the evening can actually be counterproductive for some people when it comes to sleep. While regular exercise is beneficial for overall health and can contribute to better sleep, doing it too close to bedtime can stimulate the body, making it harder to relax and fall asleep.
Choice B reason:
Watching television in bed is generally not recommended as part of good sleep hygiene. The light from the screen can interfere with the body's production of melatonin, the hormone that signals it's time to sleep, and engaging content can keep the brain alert rather than allowing it to wind down.
Choice C reason:
Taking an analgesic before bed is not a general recommendation for better sleep unless pain is a specific issue that is preventing sleep. It's important to address the root cause of insomnia rather than masking symptoms with medication.
Choice D reason:
Avoiding alcohol in the evening is a good practice for better sleep. Alcohol can disrupt the sleep cycle and lead to fragmented sleep, even though it may initially seem to help with falling asleep.
Choice E reason:
Going to bed and waking up at the same time every day helps to regulate the body's internal clock, or circadian rhythm, which can improve sleep quality. Consistency is key for this practice to be effective.
Choice F reason:
Avoiding naps, especially in the late afternoon or evening, can help ensure that you are sufficiently tired at bedtime. Napping can interfere with nighttime sleep if done too late in the day or for too long.
Choice G reason:
Eating a heavy meal before bed can lead to discomfort and indigestion, which can make it harder to fall asleep. It's best to have a light snack if needed and avoid large meals close to bedtime.
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