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 D
Explanation
The UAP is correctly pulling the client’s auricle up and back and preparing to insert the thermometer1.
Choice A is incorrect because it is not necessary to remind the UAP to locate the thermometer before gently inserting it into the ear.
Choice B is incorrect because the UAP is already demonstrating the correct technique for pulling the client’s auricle up and back1.
Choice C is incorrect because it is not necessary to advise the UAP to hold the thermometer securely in place to obtain the measurement.
Correct Answer is C
Explanation
When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.
This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.
Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.
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