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 C

Explanation

Choice A rationale: Shared responsibility is a necessary feature of a team, promoting collaboration and achievement of common goals.

Choice B rationale: Mutual independence allows team members to work together while maintaining individual contributions.

Choice C rationale: Working in the same department is not a necessary feature of a team. Teams can be effective regardless of their physical proximity.

Choice D rationale: Common purpose is essential for a team to work cohesively toward shared goals.

A. has a wound that is bleeding. B. has impaired sensation. C. is experiencing spasms of the calf muscles. D. has an active, localized inflammation.

Correct Answer is C

Explanation

Choice A rationale: Heat therapy is generally contraindicated for a wound that is bleeding, as it can increase bleeding.

Choice B rationale: Heat therapy may not be appropriate for a client with impaired sensation due to the risk of burns.

Choice C rationale: The client who is experiencing spasms of the calf muscles can benefit from heat therapy, which can help relax the muscles and reduce pain. Heat therapy increases blood flow and oxygen delivery to the affected area, which promotes healing and reduces inflammation.

Choice D rationale: Heat therapy is contraindicated for the client who has an active, localized inflammation (D), because heat can worsen the inflammation and increase the risk of infection.

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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 recognizes that which is not a necessary feature of a team?

Correct Answer is C

Explanation

The nurse recognizes that the application of heat therapy is appropriate for which client? The client who:

Correct Answer is C

Explanation

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