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 A
Explanation
Choice A rationale
Verifying the placement of the pulse oximeter is the first step to ensure the accuracy of the oxygen saturation reading. An incorrect placement can lead to inaccurate readings, and addressing this issue can help determine if further interventions are needed.
Choice B rationale
Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, this should be done after ensuring the accuracy of the initial reading.
Choice C rationale
Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low.
Choice D rationale
Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient. The goal is to improve oxygenation, not reduce it.
Correct Answer is B
Explanation
Choice A rationale
Identifying effective pain relief measures is important, but it does not directly assess the quality of the pain. This approach focuses on management rather than understanding the pain’s characteristics.
Choice B rationale
Asking the client to describe the pain is the most direct way to assess its quality. This allows the nurse to gather detailed information about the pain’s nature, intensity, and characteristics, which is crucial for accurate diagnosis and treatment.
Choice C rationale
Providing a numeric pain scale helps quantify the pain’s intensity but does not provide qualitative details about the pain’s nature. It is useful for monitoring pain levels over time but not for initial assessment.
Choice D rationale
Observing body language and movement can give clues about pain but is subjective and less reliable than directly asking the client. It should be used as a supplementary method rather than the primary approach.