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: Asking about numbness or tingling is important to rule out neurological issues that could be causing the neck pain.
Choice B reason: While heat and cold therapy may provide relief, it is not the first action to take before assessing the cause of the pain.
Choice C reason: Providing information about exercises is helpful but should come after an initial assessment.
Choice D reason: Teaching about NSAIDs is part of pain management but should follow an assessment of symptoms and potential causes.
Correct Answer is B
Explanation
Choice A reason: Stroke Volume refers to the amount of blood pumped by the left ventricle of the heart in one contraction, not to the regulation of fluid volume and cardiac output.
Choice B reason: Renin-Angiotensin-Aldosterone-System (RAAS) is responsible for vasoconstriction, sodium retention, and water reabsorption, which helps to increase circulating fluid volume and cardiac output.
Choice C reason: Brain and Atrial natriuretic peptides (BNP & ANP) actually work to decrease blood volume and pressure, not increase them.
Choice D reason: Erythropoietin primarily stimulates red blood cell production and does not directly affect fluid volume or cardiac output.
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