Difficulty: Medium
Average Score: 80%
Simulated
A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the high priority Intervention(s) for this client is/are to: (SELECT ALL THAT APPLY)
Correct answer
A,B,D
Rationale
The correct answers are A, B, and D.
A: Monitoring intake and output is crucial to assess renal function, as high potassium levels can lead to kidney damage.
B: Muscle weakness is a common symptom of hyperkalemia, indicating potential cardiac complications.
D: Obtaining a physician's order for cardiac monitoring is essential as elevated potassium levels can cause life-threatening cardiac arrhythmias.
Assessment for muscle weakness and cardiac monitoring are immediate interventions to prevent adverse outcomes. Choices C and E are incorrect as they can exacerbate hyperkalemia due to high potassium content in orange juice/bananas and the risks associated with IV potassium administration without proper dilution.
A: Monitoring intake and output is crucial to assess renal function, as high potassium levels can lead to kidney damage.
B: Muscle weakness is a common symptom of hyperkalemia, indicating potential cardiac complications.
D: Obtaining a physician's order for cardiac monitoring is essential as elevated potassium levels can cause life-threatening cardiac arrhythmias.
Assessment for muscle weakness and cardiac monitoring are immediate interventions to prevent adverse outcomes. Choices C and E are incorrect as they can exacerbate hyperkalemia due to high potassium content in orange juice/bananas and the risks associated with IV potassium administration without proper dilution.