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 B

Explanation

Choice A reason: Assessing the position of the mask on the client's face is not the priority action. The mask may be well-fitted, but the oxygen delivery may be compromised by the faulty connection of the flowmeter.

Choice B reason: Releasing and reinserting the flowmeter in the wall outlet is the best action as it may correct the problem of the loose or misaligned connection. The nurse should ensure that the flowmeter is securely attached and that the oxygen is flowing properly.

Choice C reason: Attaching the flowmeter to a humidification canister is not necessary for oxygen delivery per mask. Humidification is usually added for high-flow oxygen devices such as nasal cannula or face tent.

Choice D reason: Adjusting the flow rate to the prescribed liters per minute is not the appropriate action. The flow rate may be correct, but the oxygen delivery may be impaired by the hissing sound indicating a leak or obstruction.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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