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. The P wave represents atrial depolarization, which is initiated by the SA node, the heart's natural pacemaker.
B. The AV node is responsible for conducting impulses from the atria to the ventricles but does not initiate the P wave.
C. The Bundle of His transmits the electrical impulses to the ventricles but is not directly associated with the P wave.
D. Purkinje fibers are involved in ventricular depolarization, which corresponds to the QRS complex, not the P wave.

A. Atelectasis B. Joint contractures C. Pressure ulcers D. Renal calculi

Correct Answer is B

Explanation

A. Atelectasis is prevented primarily through deep breathing exercises and respiratory interventions, not passive ROM.
B. Passive ROM and splinting help prevent joint contractures by maintaining joint mobility and alignment, so the absence of contractures indicates successful prevention.
C. Pressure ulcers are avoided through regular repositioning and skin care rather than passive ROM alone.
D. Renal calculi are primarily prevented through hydration and diet, not passive ROM or splinting.

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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

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave?

Correct Answer is A

Explanation

A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. The absence of which finding will indicate goal achievement for the nurse's action?

Correct Answer is B

Explanation

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