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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Free Nursing Study Resources

Correct Answer is C

Explanation

Sensory overload happens when an individual is getting more input from their senses than their brain can sort through and process 1.

Therefore, reducing the stimuli in the area can help the client’s brain to better process the information being taught.

Choice A is not the answer because demonstrating the skill speaking slowly and using simple terms does not address the issue of sensory overload 1.

Choice B is not the answer because reassuring the client that the skill is not difficult to learn does not address the issue of sensory overload 1.

Choice D is not the answer because providing step-by-step written instruction does not address the issue of sensory overload 1.

A. Change coccyx dressing after performing routine care. B. Change coccyx dressing before performing routine care. C. Restate the vital importance of performing hand hygiene. D. Perform coccyx dressing change in the nursing station.

Correct Answer is C

Explanation

Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing1.

Choice A is incorrect because changing the coccyx dressing after performing routine care does not necessarily prevent the spread of MRSA to others.

Choice B is incorrect because changing the coccyx dressing before performing routine care does not necessarily prevent the spread of MRSA to others.

Choice D is incorrect because performing a coccyx dressing change in the nursing station does not necessarily prevent the spread of MRSA to others.

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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

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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