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 D
Explanation
Choice A reason: Lethargy implies a state of sluggishness, drowsiness, or fatigue, not the inability to respond to stimuli.
Choice B reason: Stupor refers to a state of near-unconsciousness or insensibility, but the patient may respond to vigorous stimulation.
Choice C reason: Obtundation describes a state of consciousness characterized by a reduced alertness and a slow response to stimuli, but not complete unresponsiveness.
Choice D reason: Comatose is the correct term for a state of deep unconsciousness in which a patient cannot be aroused, fitting the description of the patient's condition.
Correct Answer is D
Explanation
Choice A reason: An INR of 0.9 is within the normal range (0.8-1.2) and does not support the presence of bruising or bleeding disorders.
Choice B reason: A hematocrit level of 28% is below the normal range (36%-50% for women, 40%-54% for men), indicating anemia, but it does not directly explain bruising or petechiae.
Choice C reason: A WBC count of 4500 is within the normal range (4500-11000), suggesting that there is no active infection or leukocytosis that would explain the bruising.
Choice D reason: A platelet count of 60000 is below the normal range (150000-450000), which can lead to easy bruising and petechiae, supporting the nurse's observation.
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