Try our free nursing testbanks today. click here to join
Teas 7 test, Hesi A2 and Nursing prep
Nursingprepexams LEARN. PREPARE. EXCEL!
  • Home
  • Nursing
  • TEAS
  • HESI
  • Blog
Start Studying Now

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?

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.


Free Nursing Test Bank

  1. Free Pharmacology Quiz 1
  2. Free Medical-Surgical Quiz 2
  3. Free Fundamentals Quiz 3
  4. Free Maternal-Newborn Quiz 4
  5. Free Anatomy and Physiology Quiz 5
  6. Free Obstetrics and Pediatrics Quiz 6
  7. Free Fluid and Electrolytes Quiz 7
  8. Free Community Health Quiz 8
  9. Free Promoting Health across the Lifespan Quiz 9
  10. Free Multidimensional Care Quiz 10
Take full exam free

View Related questions

Correct Answer is A

Explanation

Choice A rationale

Using the syringe to remove the specimen from the catheter requires the nurse to wear gloves to maintain sterility and prevent contamination. Gloves protect both the nurse and the patient from potential pathogens present in the urine.

Choice B rationale

Transporting the urine specimen to the laboratory does not require gloves as the specimen is already secured in a biohazard bag, minimizing the risk of contamination.

Choice C rationale

Recording the output on the flowsheet in the client’s room does not involve direct contact with the urine specimen, so gloves are not necessary.

Choice D rationale

Clamping the urinary catheter prior to the collection does not require gloves as it is a preliminary step that does not involve direct contact with the urine.

Correct Answer is D

Explanation

Choice A rationale

Providing client-focused information is essential, but it does not confirm that the client has understood the critical information. It is a part of the teaching process but not a confirmation strategy.

Choice B rationale

Reinforcing key points with the client helps emphasize important information but does not ensure that the client has learned and understood it. It is a supportive strategy rather than a confirmation method.

Choice C rationale

Observing the client’s body language can provide clues about their understanding and comfort level but is not a definitive way to confirm learning. It should be used in conjunction with other strategies.

Choice D rationale

Asking the client for learning feedback is the most effective strategy for confirming that the client has understood the critical information. It encourages active participation and allows for real-time clarification.

Quick Links

Nursing Teas Hesi Blog

Resources

Nursing Test banks Teas Prep Hesi Prep Nursingprepexams Blogs
© Nursingprepexams.com @ 2019 -2026, All Right Reserved.