What should the nurse assess first? A client with chronic renal failure has a serum potassium level of 6.8 mEq/L.

The answer to this is letter D. Pulse. The patient has high potassium levels which means that there is a possibility that the person will experience cardiac arrhythmias. This is a condition wherein the heartbeat becomes irregular. It may become too fast or it may also become too slow.

This is a condition that may occur suddenly so the moment that the nurse gets the result of the patient’s potassium levels, the patient should be connected to the cardiac monitor so that the details will be more accurate. Once this has been assessed, that is the only time when the respirations, temperature, and blood pressure should be checked.

Pulse-rationale: an elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. in addition to assessing the clients pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur suddenly. the clients blood pressure may change, but only as a result of the arrhythmia. therefore, the nurse should assess blood pressure later. the nurse also may delay assessing respirations and temperature because these arent affected by the serum potassium level.