L), which intervention is most important for the nurse to implement?

Assess strength of deep tendon reflexes.

Determine apical pulse rate and rhythm.

Observe color and amount of urine.

Compare muscle strength bilaterally.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Assessing the strength of deep tendon reflexes is important in evaluating neuromuscular function, but it is not the most critical intervention for a client with hyperkalemia. Hyperkalemia primarily affects cardiac function, so monitoring the heart is crucial.

Choice B rationale

Determining the apical pulse rate and rhythm is the most important intervention for a client with a serum potassium level of 7.5 mEq/L. Hyperkalemia can cause life-threatening cardiac arrhythmias, and monitoring the heart rate and rhythm can help detect early signs of these complications.

Choice C rationale

Observing the color and amount of urine can provide information about kidney function and hydration status, but it is not the most critical intervention for hyperkalemia. The primary concern with hyperkalemia is its effect on the heart.

Choice D rationale

Comparing muscle strength bilaterally can help assess neuromuscular function, but it is not the most critical intervention for hyperkalemia. The focus should be on monitoring cardiac function to prevent life-threatening complications.

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A. Report the client’s status to the healthcare provider. B. Ask the UAP to complete postmortem care. C. Begin cardiopulmonary resuscitation (CPR) and call a code. D. Notify the family of the client’s death.

Correct Answer is A

Explanation

Choice A rationale

Reporting the client’s status to the healthcare provider is the appropriate action. The healthcare provider needs to be informed of the client’s death to provide further instructions and complete necessary documentation. This action ensures proper communication and adherence to protocols.

Choice B rationale

Asking the UAP to complete postmortem care is necessary, but it should be done after notifying the healthcare provider. The nurse must follow the proper sequence of actions to ensure all protocols are followed.

Choice C rationale

Beginning cardiopulmonary resuscitation (CPR) and calling a code is not appropriate because the client has a signed do not resuscitate (DNR) form. Performing CPR would go against the client’s wishes and legal documentation.

Choice D rationale

Notifying the family of the client’s death is important, but it should be done after reporting the client’s status to the healthcare provider. The healthcare provider may have specific instructions for communicating with the family and completing necessary documentation.

A. Send an email to facility administrators reporting the action. B. Warn the colleague that copying health information is unlawful. C. Dispose of the copies and continue with client care assignments. D. Communicate the colleague’s activities to the unit charge nurse.

Correct Answer is D

Explanation

Choice A rationale

Sending an email to facility administrators reporting the action may not be the most immediate or effective way to address the situation. It could delay the necessary intervention and does not ensure that the issue is resolved promptly.

Choice B rationale

Warning the colleague that copying health information is unlawful is important, but it may not adequately address the potential breach of patient privacy and confidentiality. The colleague may already be aware of the laws but still engage in inappropriate behavior.

Choice C rationale

Disposing of the copies and continuing with client care assignments prevents further unauthorized access to patient information but does not address the issue of the colleague’s inappropriate handling of the records. It is essential to report the incident to the appropriate authority for further investigation and follow-up.

Choice D rationale

Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.

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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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An older adult client with heart failure has a signed do not resuscitate (DNR) form in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP’s findings. Which action should the nurse take next?

Correct Answer is A

Explanation

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a countertop. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

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The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

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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?