Hesi RN Exit 3 Proctored Exam
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Hesi RN Exit 3 Proctored Exam
A client with a history of heart failure arrives at the emergency department describing an onset of fatigue and weakness. The client has been taking spironolactone 50 mg tablets PO every day. The nurse receives report from the lab that the client has a serum potassium level of 6.2 mEq/L (6.2 mmol/L). Which intervention is most important for the nurse to implement?
Explanation
A. Compare muscle strength bilaterally. While hyperkalemia can lead to muscle weakness, assessing muscle strength bilaterally is not the most critical intervention in this scenario. The priority is to assess for cardiac manifestations of hyperkalemia. B. Determine apical pulse rate and rhythm. Hyperkalemia can cause life-threatening cardiac dysrhythmias, including bradycardia, heart block, and ventricular tachycardia. Assessing the apical pulse rate and rhythm can provide essential information about cardiac function and help identify potential dysrhythmias. C. Assess strength of deep tendon reflexes. Hyperkalemia can affect neuromuscular function, leading to hyperreflexia or diminished reflexes. While assessing deep tendon reflexes is important, it is not as critical as assessing cardiac function in a client with known hyperkalemia. D. Observe color and amount of urine. While changes in urinary output and characteristics may indicate renal impairment associated with hyperkalemia, the priority in this situation is to assess for cardiac manifestations of hyperkalemia.