Reproductive System Disorders Q 48 - Gyan Darpan : Learning Portal
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Sunday 3 April 2022

Reproductive System Disorders Q 48

A male client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should nurse Olivia assess first?
    A. Blood pressure
    B. Respirations
    C. Temperature
    D. Pulse

Correct Answer: D. Pulse

An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. Hyperkalemia is defined as a serum or plasma potassium level above the upper limits of normal, usually greater than 5.0 mEq/L to 5.5 mEq/L. While mild hyperkalemia is usually asymptomatic, high levels of potassium may cause life-threatening cardiac arrhythmias, muscle weakness, or paralysis.

Option A: The client’s blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. Physical exam findings may include hypertension and edema in the setting or renal disease. There may also be signs of hypoperfusion. Muscle tenderness may be present in patients with rhabdomyolysis.
Option B: Significant muscle weakness occurs at serum potassium levels below 2.5 mmol/L but can occur at higher levels if the onset is acute. Affected muscles can include the muscles of respiration which can lead to respiratory failure and death.
Option C: The nurse also can delay assessing temperature because this isn’t affected by the serum potassium level. A study concluded that hypothermia induced hypokalemia, possibly through redistribution, and that the myocardium appears to be more sensitive to the toxic effects of K+ as hypothermia deepens.

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