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 D

Explanation

A. Client develops petechiae on the arms, legs, and abdomen: Petechiae can indicate thrombocytopenia, which may be a complication of heparin therapy but is not an urgent concern unless severe or associated with bleeding.

B. Health care provider orders Coumadin 2.5 mg P.O. to begin today: Coumadin (warfarin) is often initiated as a bridge therapy or overlap with heparin therapy in pulmonary embolism management. This order is not necessarily inappropriate and may be part of the treatment plan.

C. Client develops slight ecchymosis at the venipuncture site: Ecchymosis at the venipuncture site can occur due to minor trauma during the insertion of IV lines or blood draws and is not necessarily indicative of a complication requiring immediate notification of the healthcare provider.

D. Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds: A significantly elevated PTT indicates a potential overdose of heparin, putting the client at risk of bleeding complications. This finding warrants immediate notification of the healthcare provider for further evaluation and possible adjustment of heparin therapy.

A. "When the doctor comes to see you, we can talk about whether you will need a transplant." B. "Kidney transplantation is likely, and it would be a good idea to start talking to family members." C. "No, don't think that. You're going to be fine in a few weeks." D. "Your condition can be reversed with prompt treatment and usually will not destroy the kidney."

Correct Answer is A

Explanation

A. "When the doctor comes to see you, we can talk about whether you will need a transplant." This response acknowledges the client's concerns and opens the door for further discussion with the healthcare provider about the client's prognosis and potential need for a kidney transplant. It provides an opportunity for the client to receive accurate information from the appropriate healthcare professional.

B. "Kidney transplantation is likely, and it would be a good idea to start talking to family members." This response may cause unnecessary anxiety and speculation for the client without

confirmation from the healthcare provider. It is important to provide information based on the client's specific situation and medical assessment.

C. "No, don't think that. You're going to be fine in a few weeks." This response provides false reassurance and does not address the client's concerns or the potential seriousness of acute kidney injury. It is essential to provide honest and accurate information to the client.

D. "Your condition can be reversed with prompt treatment and usually will not destroy the kidney." While acute kidney injury can sometimes be reversible with prompt and appropriate treatment, it is not always the case. Additionally, it does not address the potential need for a kidney transplant, which depends on the severity and underlying cause of the kidney injury.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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