NCLEX-RN

Category - Physiological

Roman, a 64-year-old client, was admitted because of difficulty breathing. He reported occasional prickly chest pain and cough. Further assessment findings include edema and crackles. His laboratory results show serum creatinine of 60mmol/L and serum potassium of 6.0mmol/L. The nurse would plan care focusing on:
  1. Renal failure
  2. Impaired hepatic function
  3. Cardiac dysrhythmias
  4. Respiratory support
Explanation
Answer: C - The client has severe hyperkalemia; therefore, the nurse should initially focus the plan of care on prevention and early detection of dysrhythmias, which are life-threatening conditions. There is no renal failure since serum creatinine levels are within normal range. Hepatic function is not a problem at this moment.
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