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 C
Explanation
Choice A reason: While it is important to address any questions the patient may have, it is not the highest priority before an IVP procedure.
Choice B reason: Asking the patient to void before the procedure is a standard practice, but it is not the highest priority. The bladder should be empty to allow for clear imaging, but this can be managed at the time of the procedure.
Choice C reason: Checking for an allergy to iodine or shellfish is the highest priority because the contrast medium used in an IVP can cause severe allergic reactions in patients with these allergies. This assessment must be done before administering the contrast to prevent potentially life-threatening complications.
Choice D reason: Assessing the client's ability to remain still is important for the quality of the images, but it is not as critical as ensuring the safety of the patient regarding potential allergic reactions.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Cluster headaches are one of the main types of primary headaches, characterized by severe, unilateral pain around the eye.
Choice B reason: Tension-type headaches are the most common type of primary headache, often described as a constant pressure or tightness.
Choice C reason: Migraine headaches are a major type of headache characterized by intense, throbbing pain, often accompanied by nausea and sensitivity to light or sound.
Choice D reason: Stress-induced headaches are not typically classified as a primary type of functional headache; they may be a trigger for other types of headaches.
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