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?
Assess strength of deep tendon reflexes.
Determine apical pulse rate and rhythm.
Observe color and amount of urine.
Compare muscle strength bilaterally.
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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Correct Answer is C
Explanation
Choice A rationale
Reviewing the advanced directive document is not an immediate action to address the client’s choking and vomiting. The priority is to clear the airway and prevent aspiration.
Choice B rationale
Irrigating the nasogastric tube with water is not appropriate in this situation as it may worsen the choking and does not address the immediate need to clear the airway.
Choice C rationale
Elevating the head of the bed 45 degrees helps to clear the airway and reduce the risk of aspiration by using gravity to keep the stomach contents down.
Choice D rationale
Performing oropharyngeal suctioning may stimulate gagging and vomiting, which can exacerbate the choking.
Correct Answer is B
Explanation
Choice A rationale
Initiating a fall risk protocol is not necessary when the client demonstrates an upright posture and a smooth, steady gait. Fall risk protocols are typically initiated when there are signs of instability or a history of falls.
Choice B rationale
Recording the client’s ability to perform ADLs safely is the appropriate action. This documentation provides a baseline for the client’s functional status and helps in planning further care. It also ensures that the client’s current abilities are noted for future reference.
Choice C rationale
Determining the client’s activity tolerance is important but not the immediate next step after observing a smooth and steady gait. This assessment can be done later to evaluate the client’s endurance and capacity for physical activities.
Choice D rationale
Teaching the client to shorten the stride to prevent falls is unnecessary when the client’s gait is already smooth and steady. This advice is more relevant for clients who show signs of instability or a tendency to fall.