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: Poor tissue perfusion from circulatory insufficiency can affect oxygenation, but fluid in the lungs primarily impacts gas exchange at the alveolar level.

Choice B rationale: Decreased diffusion of oxygen from the alveoli to the blood is a major factor affecting oxygenation when fluid is present in the lungs.

Choice C rationale: Lowered oxygen carrying capacity can affect oxygenation but is not the primary concern in the presence of fluid in the lungs.

Choice D rationale: Decreased concentration of oxygen in the air is not the primary factor affecting oxygenation in a client with fluid in the lungs.

A. read previous documentation on the client's chart. B. observe the client at rest and during activity. C. ask if shortness of breath is being experienced. D. auscultate lung sounds.

Correct Answer is B

Explanation

Choice A rationale: Reading previous documentation provides historical information but may not reflect the current level of dyspnea.

Choice B rationale: Observing the client at rest and during activity is the best way to assess the current level of dyspnea.

Choice C rationale: Asking if shortness of breath is being experienced provides subjective information but may not be as reliable as direct observation.

Choice D rationale: Auscultating lung sounds is important for assessing respiratory function but may not provide a comprehensive picture of dyspnea.

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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

The nurse understands that the major factor affecting oxygenation in a client who has fluid in the lungs is:

Correct Answer is B

Explanation

The best way for the nurse to assess a client's level of dyspnea is to:

Correct Answer is B

Explanation

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