A male client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should nurse Olivia assess first?
Blood pressure
Temperature
Respirations
Pulse rate
The Correct Answer is D
Choice A reason: While blood pressure is important, hyperkalemia can cause cardiac dysrhythmias, making the pulse rate the first assessment to ensure the patient's immediate safety.
Choice B reason: Temperature is not directly affected by serum potassium levels and is not the priority in hyperkalemia.
Choice C reason: Respirations are less likely to be affected immediately by hyperkalemia compared to cardiac function.
Choice D reason: A high serum potassium level can lead to life-threatening cardiac arrhythmias, so assessing the pulse rate is the most critical initial action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hyperkalemia is a common electrolyte imbalance in prerenal AKI due to decreased kidney function and the inability to excrete potassium.
Choice B reason: Hypernatremia is not typically expected in prerenal AKI unless there is an associated condition causing increased sodium retention.
Choice C reason: Hypercalcemia is not commonly associated with prerenal AKI.
Choice D reason: Hypophosphatemia is less likely in prerenal AKI; hyperphosphatemia is more common due to decreased filtration of phosphate.
Correct Answer is D
Explanation
Choice A reason: Painful and red-tinged urination could be related to kidney stones but is not directly relevant to the preparation for an intravenous pyelogram.
Choice B reason: The end of the menstrual period is not typically relevant to the preparation for an intravenous pyelogram.
Choice C reason: Drinking fluids is generally encouraged but does not need to be reported unless it is restricted before the procedure.
Choice D reason: The client's allergy to shellfish is important to report because the contrast dye used in an intravenous pyelogram may contain iodine, which can cause a reaction in people with shellfish allergies.
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