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

While drying the client’s feet, the nurse should emphasize the need to thoroughly dry between the toes.

Moisture between the toes can create a breeding ground for bacteria and fungi, which can lead to infections such as athlete’s foot 1.

Choice A is not the answer because drying on the dorsal surfaces of the feet is not as important as drying between the toes 1.

Choice C is not the answer because drying over the heels is not as important as drying between the toes 1.

Choice D is not the answer because drying around the ankles is not as important as drying between the toes 1.

A. Elevate the head of the bed to a 45-degree angle B. Apply the client's positive airway pressure device C. Lift and lock the side rails in place D. Remove dentures or other oral appliances

Correct Answer is B

Explanation

The client has difficulty sleeping due to obstructive sleep apnea (OSA), and using a positive airway pressure device can help keep their airway open and prevent dangerous pauses in breathing while they sleep 1.

Choice A is not the answer because elevating the head of the bed to a 45-degree angle may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.

Choice C is not the answer because lifting and locking the side rails in place is a safety measure but does not directly address the client’s OSA 1.

Choice D is not the answer because removing dentures or other oral appliances may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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