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. 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.

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A. I’m sorry, but your child’s medical information is none of your business. B. I can give you those results as soon as I get them back from the laboratory. C. I can only give medical information to your child because they are legally an adult. D. The healthcare provider will share this information with you.

Correct Answer is C

Explanation

Choice A rationale

Telling the parents that their child’s medical information is none of their business is not appropriate. It is important to communicate respectfully and explain the legal status of the emancipated minor.

Choice B rationale

Promising to give the results to the parents as soon as they are back from the laboratory is not appropriate. The nurse should respect the legal status of the emancipated minor and their right to privacy.

Choice C rationale

Informing the parents that the nurse can only give medical information to their child because they are legally an adult is the best response. This explains the legal status of the emancipated minor and respects their autonomy.

Choice D rationale

Telling the parents that the healthcare provider will share the information with them is not appropriate. The nurse should respect the legal status of the emancipated minor and their right to privacy.

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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 B

Explanation

Correct Answer is C

Explanation

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Take full exam for free 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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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?

Correct Answer is B

Explanation

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking querry about the client’s laboratory results. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

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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?