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 C
Explanation
The best response for the nurse to provide is “I can only give medical information to your son because he is an adult.” Since the client is 19 years old and considered an adult, the nurse must respect the client’s right to privacy and confidentiality.
Choice A is not the answer because it is rude and unprofessional.
Choice B is not the answer because it does not address the issue of privacy and confidentiality.
Choice D is not the answer because it does not address the issue of privacy and confidentiality.
Correct Answer is C
Explanation
Antibiotics can have side effects that may contribute to fatigue and difficulty sleeping.
Choice A is not the correct answer because reading a book about how to sleep better is not a contributing factor to fatigue and difficulty sleeping.
Choice B is not the correct answer because exercising in the morning and afternoon can actually help improve sleep.
Choice D is not the correct answer because sleeping between 10 PM and 9 AM each night is a normal sleep schedule and should not contribute to fatigue and difficulty sleeping.
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