The nurse is reviewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L and Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

Request a CT scan of the head.

Assess for Chvostek’s sign.

Obtain a chest X-ray.

Obtain a 12-lead ECG.

Answer and Explanation

The Correct Answer is D

A. A CT scan of the head is not indicated based on the laboratory findings provided. The priority intervention is related to the elevated potassium level.
B. Chvostek’s sign is associated with hypocalcemia (low calcium levels), not hyperkalemia (high potassium levels).
C. A chest X-ray is not the priority intervention for elevated potassium. The primary concern is the potential for cardiac arrhythmias related to the high potassium level.
D. Hyperkalemia (potassium 6.6 mEq/L) can lead to cardiac arrhythmias. The nurse should obtain a 12-lead ECG to assess for any changes in the heart's electrical activity, which could indicate serious complications like arrhythmias or cardiac arrest.

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Correct Answer is B

Explanation

A. Advising the client to add citrus juices and bananas is inappropriate because these are high in potassium and would further increase the already elevated potassium level, potentially worsening hyperkalemia.
B. Obtaining a 12-lead ECG is the correct action. A potassium level of 6.8 mEq/L is critically high and can cause life-threatening cardiac arrhythmias. An ECG can help identify hyperkalemia-related changes, such as peaked T waves, widened QRS complexes, or arrhythmias.
C. While obtaining a serum sodium level might provide additional information, it does not address the immediate risk posed by the elevated potassium level. The priority is assessing the cardiac effects of hyperkalemia.
D. Suggesting that the client use a salt substitute is incorrect, as many salt substitutes contain potassium chloride, which could worsen hyperkalemia.

A. Decreased urine output B. Ascending muscle paralysis C. Hypoglycemia D. Ascites

Correct Answer is B

Explanation

A. Decreased urine output is not directly associated with elevated potassium levels. It is more commonly linked to renal failure or dehydration.
B. Hyperkalemia (high potassium levels) can lead to ascending muscle paralysis due to its effects on the neuromuscular system. Potassium is critical for proper muscle function, and elevated levels can disrupt the electrical impulses needed for muscle contraction, potentially causing paralysis.
C. Hypoglycemia is unrelated to elevated potassium levels. It is more often associated with insulin use, inadequate food intake, or certain medical conditions.
D. Ascites is fluid accumulation in the abdomen, usually caused by liver disease or heart failure, and is not a direct complication of hyperkalemia.

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The nurse is reviewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L and Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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