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.

Answer and Explanation

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).

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Correct Answer is B

Explanation

To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus.

Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.

Choice A is not the answer because tapping the feet forwards and backwards exercises the ankle joint, which is not a hinge joint.

Choice C is not the answer because turning the head to the right and left exercises the pivot joint in the neck, which is not a hinge joint.

Choice D is not the answer because extending the arm at the side and rotating in circles exercises the ball-and-socket joint in the shoulder, which is not a hinge joint.

A. Placing a client in restraints without having a healthcare provider's order. B. Administering the medication to a client behind a closed curtain. C. Enlisting security personnel to assist with restraining the client. D. Informing a client that the medication being administered is a sedative.

Correct Answer is A

Explanation

Placing a client in restraints without having a healthcare provider’s order.

It is inappropriate for a nurse to place a client in restraints without having a healthcare provider’s order.

Choice B is not the answer because administering the medication to a client behind a closed curtain is not necessarily inappropriate.

Choice C is not the answer because enlisting security personnel to assist with restraining the client may be necessary in some situations.

Choice D is not the answer because informing a client that the medication being administered is a sedative is not necessarily inappropriate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Correct Answer is B

Explanation

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse is inappropriate?

Correct Answer is A

Explanation

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