When using a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
Compare muscle strength bilaterally.
Determine apical pulse rate and rhythm.
Measure color and amount of urine.
Assess strength of deep tendon reflexes.
The Correct Answer is B
Hyperkalemia is a condition where there is an elevated level of potassium in the blood.
It can occur in patients with renal disease due to the kidneys’ reduced ability to excrete potassium.
Treatment-related side effects, such as certain medications or chemotherapy, can also contribute to hyperkalemia by altering potassium levels in the body1.
Hyperkalemia can lead to life-threatening cardiac conduction disturbances2.
Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.
Choice A is not correct because comparing muscle strength bilaterally is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Choice C is not correct because measuring color and amount of urine is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Choice D is not correct because assessing strength of deep tendon reflexes is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient’s self-reporting is widely considered as the key to effective pain management 1.
According to good practice guidelines, clinicians must accept a patient’s statement, regardless of their own opinions 1.
Choice A is not the answer because asking the client to describe the pain does not provide an objective measure of pain intensity 1.
Choice C is not the answer because identifying effective pain relief measures does not assess the intensity of the client’s pain 1.
Choice D is not the answer because observing body language and movement does not provide an objective measure of pain intensity 1.
Correct Answer is D
Explanation
The correct answer is choice D.
When administering ear drops to an adult client with an ear infection, the nurse should keep the patient in a supine position to administer the drops.
This position allows the medication to flow into the ear canal and reach the site of infection.
Choice A is not correct because it is not necessary to swab and shake the bottle before administering the drops.
Choice B is not correct because tilting the head upright would cause the medication to flow out of the ear canal instead of reaching the site of infection.
Choice C is not correct because lowering the edge of the dropper into the canal of the ear could cause injury or discomfort to the patient.
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