The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?
Cardiac
Neurological
Gastrointestinal
Respiratory
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While monitoring cardiac output can provide insights into heart function, it does not directly determine the presence of dysrhythmias.
B. Peripheral extremity circulation is influenced by cardiac output but is not the primary focus of monitoring it.
C. Cardiac output is essential for determining the heart's ability to meet the body's oxygenation requirements; low cardiac output can lead to inadequate oxygen delivery.
D. Ventilation status refers to the respiratory function and is not directly assessed through cardiac output measurements.
Correct Answer is B
Explanation
A. Performing movements until the patient reports pain is inappropriate in passive range of motion, as the goal is to maintain joint function without causing discomfort.
B. Moving each joint to the point of resistance helps to maintain flexibility and prevent stiffness without causing harm, making this the appropriate technique.
C. Repeating movements five times by the patient is not applicable for passive range of motion, which is performed by the nurse on a patient who cannot do it themselves.
D. While smooth movements are essential, they should not be done quickly; the focus should be on the patient's comfort and safety, avoiding rapid or jerky motions.
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