The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?

Cardiac

Neurological

Gastrointestinal

Respiratory

Answer and Explanation

The Correct Answer is A

A. Hyperkalemia can lead to dangerous cardiac arrhythmias and other heart-related complications due to its effect on the electrical conduction system of the heart, making cardiac assessment the priority.
B. While neurological assessment is important in various conditions, it is secondary to assessing cardiac status in hyperkalemia.
C. Gastrointestinal symptoms can occur with hyperkalemia, but they do not pose an immediate life-threatening risk like cardiac issues do.
D. Respiratory assessment is essential in many contexts, but the immediate threat of hyperkalemia lies in its impact on heart function, making cardiac assessment the most critical.

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Correct Answer is A

Explanation

A. "Readiness for enhanced urinary elimination" is classified as a health promotion diagnosis, indicating the patient’s desire to improve their health condition and adopt new health behaviors.
B. A risk diagnosis is used when there is a potential for problems to occur, not applicable in this scenario as the patient is actively seeking improvement.
C. A problem-focused diagnosis describes an existing problem that requires intervention; this situation reflects readiness for improvement, not an existing issue.
D. A collaborative problem involves potential complications that require both nursing and medical management; this case focuses on the patient's willingness to learn a self-management skill rather than managing a specific medical problem.

A. Patient will have one soft, formed bowel movement by end of shift. B. Patient will not take any pain medications this shift. C. Patient will walk unassisted to bathroom by the end of shift. D. Patient will be offered laxatives or stool softeners this shift.

Correct Answer is A

Explanation

A. This outcome is specific, measurable, and directly addresses the goal of managing constipation by aiming for a bowel movement.
B. Discontinuing pain medication abruptly may be unrealistic and can cause distress for the patient.
C. Ambulation may help with constipation but does not directly measure or ensure bowel movement.
D. Offering laxatives or stool softeners is an intervention rather than a measurable patient outcome.

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The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

Correct Answer is A

Explanation

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