A client diagnosed with End Stage Renal Disease (ESRD) has a potassium level of 6.8 mEq/L. Which of the following priority actions should the nurse implement?

Instruct the client to avoid high-potassium foods.

Redraw the potassium to verify results.

Check the client's blood pressure.

Obtain a serum sodium level.

Answer and Explanation

The Correct Answer is C

A. Instruct the client to avoid high-potassium foods: While important for long-term management, it is not the priority when the client is experiencing hyperkalemia, as immediate interventions are necessary to prevent complications.

B. Redraw the potassium to verify results: Redrawing the potassium may be necessary if there is concern about sample contamination or if the result is significantly different from what is expected. However, it is not the priority when the client is at risk of complications from hyperkalemia.

C. Check the client's blood pressure: This is the priority action because hyperkalemia can lead to cardiac dysrhythmias, including potentially life-threatening arrhythmias. Checking the blood pressure helps assess the client's cardiovascular status and any potential effects of hyperkalemia on cardiac function.

D. Obtain a serum sodium level: While monitoring electrolyte levels is important in ESRD, sodium levels are not the priority when the client is experiencing hyperkalemia. Monitoring potassium and managing its effects take precedence.

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Correct Answer is B

Explanation

A. Assist with passive range of motion exercises: While promoting mobility is important for overall well-being, it may not be the priority in a client with Pneumocystis jirovecii pneumonia, which requires respiratory support and oxygenation.

B. Monitor the pulse oximetry every two hours: Monitoring oxygen saturation is crucial in clients with Pneumocystis jirovecii pneumonia to assess respiratory status and the effectiveness of treatment. Hypoxemia is a common complication and requires prompt intervention.

C. Encourage 1 liter of fluid intake in 24 hours: Encouraging adequate fluid intake is important for hydration, but it may not be the priority over monitoring respiratory status in a client with pneumonia.

D. Encourage the client to focus efforts on discharge: Discharge planning is important but should not take precedence over immediate nursing care priorities such as respiratory assessment and monitoring.

A. Poorly coordinated care and nosocomial infections are examples of errors. B. Handoff errors are not causes of adverse events. C. Medication errors are intentional. D. As many as 10% of medication errors are preventable.

Correct Answer is A

Explanation

A. Poorly coordinated care and nosocomial infections are examples of errors: Poorly coordinated care, such as miscommunication between healthcare providers or lack of continuity in care, and nosocomial infections (infections acquired in the healthcare setting) are examples of errors that can compromise patient safety and contribute to adverse events.

B. Handoff errors are not causes of adverse events: Handoff errors, including miscommunication during transitions of care, are significant contributors to adverse events in healthcare settings. Improper handoffs can lead to misunderstandings, delays in treatment, and errors in medication administration.

C. Medication errors are intentional: Medication errors are unintended and can occur due to various factors, including human error, system failures, and communication breakdowns. They are not intentional acts.

D. As many as 10% of medication errors are preventable: Medication errors are often preventable with the implementation of safety measures such as barcode scanning, medication reconciliation, and standardized protocols. The percentage of preventable medication errors may vary depending on the healthcare setting and the effectiveness of safety initiatives.

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A client diagnosed with End Stage Renal Disease (ESRD) has a potassium level of 6.8 mEq/L. Which of the following priority actions should the nurse implement?

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