A patient with a history of heart failure presents at the emergency department reporting fatigue and weakness. The patient has been taking 50 mg spironolactone tablets orally every day.

The nurse receives a lab report indicating the patient’s serum potassium level is 6.2 mEq/L (6.2 mmol/L). What is the most important intervention for the nurse to implement?

Compare muscle strength bilaterally.

Observe the color and amount of urine.

Determine the apical pulse rate and rhythm.

Assess the strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Comparing muscle strength bilaterally is not the most important intervention in this situation. While muscle weakness can be a symptom of hyperkalemia, it is not the most immediate concern. Hyperkalemia can lead to life-threatening cardiac dysrhythmias, which is a more immediate threat to the patient’s life.

Choice B rationale

Observing the color and amount of urine can provide information about the patient’s renal function, which is important in the regulation of potassium. However, this is not the most immediate concern when a patient’s serum potassium level is dangerously high.

Choice C rationale
Determining the apical pulse rate and rhythm is the most important intervention. Hyperkalemia can cause cardiac dysrhythmias, so the nurse should immediately assess the patient’s heart rate and rhythm. The nurse should also place the patient on a cardiac monitor, if not already done, and notify the healthcare provider immediately.

Choice D rationale
Assessing the strength of deep tendon reflexes can provide information about neuromuscular function, which can be affected by hyperkalemia. However, this is not the most immediate concern. The nurse’s priority is to assess and monitor for life-threatening cardiac dysrhythmias.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","F"]

Explanation

Choice A rationale
Performing a thorough physical assessment is crucial when elder mistreatment is suspected. It helps to identify any signs of physical abuse or neglect.
Choice B rationale
Developing a safety plan is an important step in ensuring the safety of the elder. This plan can include strategies to avoid potential harm and steps to take if the elder feels unsafe.
Choice C rationale

Taking photographs to document the abuse or neglect can provide concrete evidence of the mistreatment. These photographs can be used in investigations and legal proceedings.
Choice F rationale
Completing a comprehensive history is necessary to understand the full context of the elder’s situation. This includes the elder’s health status, living conditions, and the nature of their relationship with the caregiver.
Choice H rationale
Reporting findings to Adult Protective Services is a critical step in addressing elder mistreatment. Adult Protective Services can conduct further investigations and take necessary actions to protect the elder.

A. I should clean the face mask once per shift B. I should place the mask first over the nose and then cover the mouth C. The client should take a 1 to 2 minute break from the face mask each hour D. The mask should cover only the mouth and leave the nose open for expiration E. I can adjust the oxygen level

Correct Answer is ["B","C","E"]

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Correct Answer is ["A","B","C","F"]

Explanation

Mark whether the statements by the new graduate nurse indicate understanding or no understanding of the use of the face mask in the care of this client.

Correct Answer is ["B","C","E"]

A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes. Which behaviors should the nurse prioritize for monitoring?

Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?

The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother’s care.

A client with gout in the left great toe has received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom is most important for the client to report to the healthcare provider?

The nurse is preparing a client with breast cancer for BRCA1 and BRCA2 genetic testing. Which pathophysiological process should the nurse use to support client teaching?

The patient provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye-opener) query. What interpretation should the nurse provide to the patient?