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 B
Explanation
If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation.
Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation 1.
Therefore, the nurse should obtain the respiratory rate first.
Choice A is not the answer because determining pulse pressure will not provide any significant indication of respiratory distress 1.
Choice C is not the answer because temperature does not provide any significant data about the use of accessory muscles in respiration 1.
Choice D is not the answer because pulse rate does not provide any significant data about the use of accessory muscles in respiration 1.
Correct Answer is B
Explanation
Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.
When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration1.
Choice A is incorrect because brushing an unconscious client’s teeth should not be avoided.
In fact, it is recommended that you brush your teeth at least once every four hours1.
Choice C is incorrect because unconscious clients need regular mouth care just like conscious clients2.
Choice D is incorrect because positioning the unconscious client upright is not the best method.
Instead, they should be placed in a side-lying position to prevent aspiration1.
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