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","B","C","D"]

Explanation

A. A patient with an indwelling catheter requires regular perineal care to prevent infection due to increased risk from the catheter.
B. Urinary and fecal incontinence increase the risk of skin breakdown and infection, necessitating frequent perineal care.
C. Surgical dressings in the rectal and genital areas require perineal care to maintain hygiene and prevent wound contamination.
D. Bariatric patients often need regular perineal care due to skin folds and increased risk of moisture-related skin breakdown.
E. A circumcised, ambulatory male typically has a lower risk of infection and may not require as frequent perineal care unless other factors are present.

A. The arms hang comfortably at the sides. B. The edge of the seat is in contact with the popliteal space. C. Both feet are supported on the floor with ankles flexed. D. The body weight is directly on the buttocks only.

Correct Answer is A

Explanation

A. This observation indicates proper body alignment as the arms hanging comfortably at the sides suggest relaxation and good posture.
B. The edge of the seat should not be in contact with the popliteal space; there should be a small gap to prevent pressure and improve circulation.
C. While the feet should be supported on the floor, they should be flat rather than flexed at the ankles for optimal alignment.
D. The body weight should be distributed between the buttocks and thighs, not just on the buttocks, to promote comfort and good posture.

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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

Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)

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

Explanation

The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding?

Correct Answer is A

Explanation

Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

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