When using 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?

Compare muscle strength bilaterally.

Determine apical pulse rate and rhythm.

Measure color and amount of urine.

Assess strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is B

Hyperkalemia is a condition where there is an elevated level of potassium in the blood.

It can occur in patients with renal disease due to the kidneys’ reduced ability to excrete potassium.

Treatment-related side effects, such as certain medications or chemotherapy, can also contribute to hyperkalemia by altering potassium levels in the body1.

Hyperkalemia can lead to life-threatening cardiac conduction disturbances2.

Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.

Choice A is not correct because comparing muscle strength bilaterally is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).

Choice C is not correct because measuring color and amount of urine is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).

Choice D is not correct because assessing strength of deep tendon reflexes is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).

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Correct Answer is C

Explanation

The most important intervention the nurse should take when administering these medications to the client is to assess the client’s pain level and administer the appropriate medication based on the level of pain.

Choice A is not the correct answer because administering all medications at the same time may not provide effective pain relief and could result in overmedication.

Choice B is not the correct answer because administering the medication with the highest dose first may not provide effective pain relief and could result in overmedication.

Choice D is not the correct answer because administering the medication with the longest duration of action first may not provide immediate pain relief.

A. Instruct the unlicensed assistive personnel to frequently offer oral fluids. B. Prepare to implement a pressure redistribution mattress. C. Explain to the client that the wound needs debridement. D. Obtain hemoglobin of the side to check for anemia and sensitivity.

Correct Answer is B

Explanation

Pressure redistribution is an important part of preventing and treating pressure sores1.

Choice A is not the answer because offering oral fluids does not directly address the issue of pressure sores.

Choice C is not the answer because debridement is a surgical procedure that removes dead tissue from a wound and may not be necessary in this case.

Choice D is not the answer because checking for anemia and sensitivity does not directly address the issue of pressure

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When using 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

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When using 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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