Editing Reduction of Risk Potential – RN Practice Questions (section)

==Question 8==
Which client should the nurse on a medical-surgical unit assess first?
# A client two days after abdominal surgery with a temperature of 37.9 degrees Celsius (100.2 degrees Fahrenheit) and diminished breath sounds at both bases.
# A client with chronic kidney disease whose serum potassium is 5.9 mEq/L and who reports new muscle weakness.
# A client with cirrhosis whose serum albumin is 2.6 g/dL and who has 2+ pitting ankle edema.
# A client with type 2 diabetes whose fasting glucose is 168 mg/dL.

'''Answer:''' Option 2. The client with chronic kidney disease, potassium 5.9 mEq/L, and new muscle weakness.

''Rationale:'' Hyperkalemia with new neuromuscular symptoms threatens lethal dysrhythmia and takes precedence over all the other findings. Option 1 most likely represents atelectasis, which is expected and important but not immediately life threatening. Options 3 and 4 are chronic, expected findings consistent with each client's diagnosis. The prioritization rule is unstable over stable and unexpected over expected, with cardiac risk at the top.