A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?

Choice A reason: Dry mucous membranes signal dehydration, not hyperkalemia directly. High potassium affects cardiac and nerve function, not mucosal hydration status in renal failure.

Choice B reason: Hyperactive reflexes occur in hypocalcemia, not hyperkalemia. Excess potassium depresses nerve and muscle activity, often reducing reflexes instead of enhancing them.

Choice C reason: Trousseau’s sign indicates hypocalcemia, with carpal spasm from cuff pressure. Hyperkalemia in renal failure doesn’t trigger this; it’s a calcium issue.

Choice D reason: Irregular heart rate, like bradycardia or arrhythmias, stems from hyperkalemia’s effect on cardiac conduction. In renal failure, potassium excess disrupts rhythms critically.

Choice A reason: Every 2 hours for wheezing is incorrect; montelukast is daily, not PRN. Scientifically, it’s a leukotriene inhibitor for prevention, not acute relief, showing misunderstanding of its chronic asthma management role versus rescue inhalers.

Choice B reason: Once daily in the evening is correct for montelukast, optimizing its anti-inflammatory effect overnight. Scientifically, this aligns with pharmacokinetics and asthma’s nocturnal worsening, indicating accurate understanding of its administration for long-term control.

Choice C reason: Stopping with steroids is wrong; montelukast complements, not replaces, them. Scientifically, it targets different pathways (leukotrienes vs. corticosteroids), and combined use enhances control, reflecting a misgrasp of its additive role in asthma therapy.

Choice D reason: Two months for efficacy is false; montelukast acts within days. Scientifically, its leukotriene blockade reduces inflammation quickly, not over months, suggesting misunderstanding of its rapid onset in asthma symptom prevention per evidence.