In reviewing the electrolytes of a patient, the nurse notes the serum potassium level has increased from 4.3 mEq/L to 5.9 mEq/L. Which assessment does the nurse initiate first to prevent further harm?
Oxygen Stats
Pulse rate and Rhythm
Respiratory rate and depth
Deep tendon reflexes
The Correct Answer is B
An increased serum potassium level, also known as hyperkalemia, can have adverse effects on the electrical conduction of the heart, potentially leading to life-threatening cardiac dysrhythmias. Therefore, it is crucial to assess the patient's pulse rate and rhythm promptly to identify any abnormal cardiac activity.
Assessing the oxygen saturation (oxygen stats), respiratory rate and depth, and deep tendon reflexes are also important assessments, but they are not the priority in this case. Hyperkalemia primarily affects cardiac function, and prompt identification of any potential cardiac rhythm disturbances is essential to prevent further harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
a. Considered primary treatment for small cell lung cancer (SCLC): Chemotherapy b. Used to prevent metastasis to the brain: Prophylactic cranial radiation
c. Electric current heats and destroys tumor cells: Radiofrequency ablation d. Best procedure for cure of lung cancer: Surgery
e. Medications that block molecules involved in tumor: Biologic and targeted
Correct Answer is D
Explanation
The red tag is used to identify patients with critical injuries who require immediate medical attention. These individuals have life-threatening conditions that, with prompt medical intervention, have a higher chance of survival.
The triage color code system typically follows the following priority order:
1. Red tag: Immediate or emergent care needed for life-threatening injuries or conditions.
2. Yellow tag: Urgent care needed for significant injuries or conditions that are not immediately life-threatening.
3. Green tag: Non-urgent care needed for minor injuries or illnesses that can wait for medical treatment.
4. Black tag: Comfort care or deceased, as the injuries or conditions are incompatible with life or resources are not available for treatment.
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