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. On the dorsal surfaces. B. Between the toes. C. Over the heels. D. Around the ankles.

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.

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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

The nurse is caring for a male client with decreased circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry the feet. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

Correct Answer is B

Explanation

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