Practice Question
A client with a history of heart failure arrives at the emergency department describing an onset of fatigue and weakness. Theclient 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?
Answer Choices:
Correct Answer:
Determine apical pulse rate and rhythm.
Rationale:
💊 Spironolactone is potassium-sparing, and a serum potassium level of 6.2 mEq/L is dangerously elevated.
💊 Hyperkalemia can cause life-threatening cardiac arrhythmias, especially bradycardia or irregular rhythms.
💊 Monitoring the apical pulse provides the most accurate insight into cardiac rhythm changes caused by high potassium.
💊 An abnormal apical pulse may indicate the need for emergency interventions, such as ECG or medication adjustment.
💊 This action directly correlates with the client’s most critical risk—cardiac arrest due to electrolyte imbalance.
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This question is from RN-HESI Exit~2023 Exam 4 which contains 115 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI-Exit Exam(s)
- Domain: HESI Exit Exam(s)~2023
- Answer Choices: 4