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 C

Explanation

This response shows that the nurse is willing to listen and provide support to the client.

It also allows the client to decide if they want to talk and share their feelings.

Choice A is not correct because it is not the most therapeutic response.

While it does encourage the client to talk about their visit with their significant other, it does not show that the nurse is willing to listen and provide support.

Choice B is not correct because it is not the most therapeutic response.

While it does acknowledge that the client may be feeling lonely, it does not show that the nurse is willing to listen and provide support.

Choice D is not correct because it is not the most therapeutic response.

While it does encourage the client to talk about their visit, it does not show that the nurse is willing to listen and provide support.

A. 3 mL syringe and a sterile needle. B. One ounce medicine cup. C. 3 mL syringe. D. Tuberculin syringe.

Correct Answer is C

Explanation

A. 3 mL syringe and a sterile needle.
This is incorrect. A sterile needle is unnecessary for administering an oral medication. Syringes with needles are used for injections, not for measuring or delivering oral medications.

B. One ounce medicine cup.
This is incorrect. While a medicine cup can be used for liquid medications, it is not precise for small volumes such as 2 mL. The graduations on a medicine cup are typically in larger increments, making it difficult to measure accurately.

C. 3 mL syringe.
This is correct. A 3 mL syringe is precise and suitable for measuring a 2 mL dose of a viscous liquid. Syringes provide clear markings, ensuring accurate measurement of small volumes. Additionally, the absence of a needle makes it appropriate for oral administration.

D. Tuberculin syringe.
This is incorrect. Although a tuberculin syringe can accurately measure small doses, it is designed for very small volumes, such as 1 mL or less. A 3 mL syringe is more appropriate for a 2 mL dose.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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