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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?

A.

Assess strength of deep tendon reflexes.

B.

Determine apical pulse rate and rhythm.

C.

Observe color and amount of urine.

D.

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Ensuring the bevel of the needle is pointing up is crucial for intradermal injections as it allows the medication to be deposited just below the epidermis, forming a small bleb or wheal.

Choice B rationale

The upper arm is not the preferred site for intradermal injections. The inner forearm and upper back are more commonly used as they allow for better visualization of the reaction.

Choice C rationale

Holding the syringe perpendicular to the skin is incorrect for intradermal injections. The correct angle is 5 to 15 degrees to ensure the medication is deposited in the dermis.

Choice D rationale

Massaging the site gently after injection is not recommended for intradermal injections as it can disperse the medication and affect the test results.

Correct Answer is ["B","E"]

Explanation

Choice A rationale

Drinking a mixture of warm water, whiskey, and honey at bedtime is not recommended as alcohol can disrupt sleep patterns and lead to poor sleep quality.

Choice B rationale

Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and can improve sleep quality.

Choice C rationale

Asking for a mild sedative should be a last resort and only used under the guidance of a healthcare provider. Non-pharmacological methods are preferred for improving sleep

.

Choice D rationale

Taking an afternoon nap can interfere with nighttime sleep and is generally not recommended for those having trouble sleeping at night.

Choice E rationale

Avoiding caffeinated beverages late in the day can help improve sleep quality as caffeine is a stimulant that can interfere with falling asleep.

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