When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Determine apical pulse rate and rhythm.

Observe color and amount of urine.

Compare muscle strength bilaterally.

Assess strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client's heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.

Choice B reason: This is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client's renal function and fluid balance, but these are not the priority assessments.

Choice C reason: This is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client's neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.

Choice D reason: This is another incorrect intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client's reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.

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Correct Answer is A

Explanation

Choice A reason: This is the most important instruction because lowering the bed reduces the risk of injury to both the client and the UAP. It also makes it easier for the UAP to use proper body mechanics and leverage when assisting the client to move up in bed.

Choice B reason: This is not the most important instruction because encouraging the client to eat all of the meals that are sent is not directly related to repositioning the client. While adequate nutrition is important for wound healing and recovery, the nurse should assess the client's appetite, dietary needs, and preferences before instructing the UAP to encourage the client to eat.

Choice C reason: This is also not the most important instruction because offering fruit juice at least twice during both the day and evening shifts is not directly related to repositioning the client. While adequate hydration is important for preventing constipation and promoting circulation, the nurse should consider the client's fluid status, blood sugar levels, and potential interactions with medications before instructing the UAP to offer fruit juice.

Choice D reason: This is another incorrect instruction because having the client hold a pillow over the abdomen to cough and deep breathe is not directly related to repositioning the client. While coughing and deep breathing are important for preventing respiratory complications and promoting oxygenation, the nurse should instruct the client to perform these exercises at regular intervals, not only when repositioning.

A. To avoid pain-causing activity. B. To take analgesics as prescribed. C. To show evidence of incision healing. D. To ambulate without discomfort.

Correct Answer is D

Explanation

Choice A reason: To avoid pain-causing activity is not the best outcome statement for the nurse to include in this client's plan of care. It does not address the problem of activity intolerance, but rather reinforces the client's refusal to ambulate. It may also delay the client's recovery and increase the risk of complications.

Choice B reason: To take analgesics as prescribed is a relevant outcome statement for the nurse to include in this client's plan of care, but not the best one. It may help to reduce the client's pain and improve his comfort, but it does not directly measure the client's activity tolerance or mobility.

Choice C reason: To show evidence of incision healing is an important outcome statement for the nurse to include in this client's plan of care, but not the best one. It indicates the client's progress and recovery from surgery, but it does not reflect the client's activity intolerance or pain level.

Choice D reason: To ambulate without discomfort is the best outcome statement for the nurse to include in this client's plan of care. It addresses the problem of activity intolerance related to pain, and the goal of increasing the client's mobility and function. It also implies that the client's pain is well-managed and his incision is healing.

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When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

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Correct Answer is A

Explanation

Correct Answer is D

Explanation

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