A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to: (SELECT ALL THAT APPLY)

dilute potassium elixir in juice prior to administration.

monitor intake and output every shift

assess the client for muscle weakness and flaccid paralysis.

encourage intake of orange juice or a banana with each meal

obtain a physician's order for cardiac monitoring

Answer and Explanation

Correct Answer : C,E

Choice A rationale: Diluting potassium elixir in juice is not a priority intervention for a critically elevated potassium level. Immediate actions are needed.

Choice B rationale: Monitoring intake and output is important, but it is not the highest priority when the potassium level is critically elevated.

Choice C rationale: Assessing the client for muscle weakness and flaccid paralysis is a high priority because hyperkalemia can lead to serious cardiac and neuromuscular complications.

Choice D rationale: Encouraging intake of orange juice or a banana may be appropriate for managing mild hypokalemia, but it is not the priority for a client with critically elevated potassium.

Choice E rationale: Obtaining a physician's order for cardiac monitoring is crucial, as hyperkalemia can lead to life-threatening cardiac dysrhythmias.

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Correct Answer is B

Explanation

Choice A rationale: Administering the medication against the client's will is not respectful of the client's autonomy and right to make decisions about her own care.

Choice B rationale: Withholding the medication and reporting it to the prescriber is appropriate. The prescriber can reassess the situation and determine the next course of action.

Choice C rationale: Withholding the medication and filing an incident report may be premature; it is essential to involve the prescriber first.

Choice D rationale: Informing the client that the medication must be taken until the nurse gets an order to discontinue it may not be the best approach, as it does not respect the client's right to refuse treatment. The prescriber should be involved in the decision-making process.

A. may be caused when one layer of tissue slides over another layer of tissue. B. requires dressing changes twice daily to promote healing. C. is usually caused by overhydration. D. is a partial thickness injury caused by pressure

Correct Answer is A

Explanation

Choice A rationale: A DTI is a type of pressure injury that occurs when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for a prolonged period of time.

Choice B rationale: Dressing changes for a DTI would depend on the severity and characteristics of the injury, but a specific frequency is not universally prescribed. Choice C rationale: A DTI is not typically caused by overhydration but is associated with pressure-related damage to underlying tissues.

Choice D rationale: DTI is not a partial thickness injury, but rather an injury to the deep layers of tissue that may not be visible on the surface. A partial thickness injury involves damage to the epidermis and/or dermis, such as a stage 2 pressure ulcer.

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A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

An alert, competent client refuses to take her antihypertensive medication. The nurse has explained why the medication is important and the client states that she understands but doesn't want to take the medication. What is the best nursing action?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to: (SELECT ALL THAT APPLY)

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