A client with acute renal failure is at risk of developing hyperkalemia. What clinical manifestation is the most critical indicator of severe hyperkalemia in this client?

Muscle weakness and fatigue.

Tingling sensations in the extremities.

Irregular heart rhythm (dysrhythmiA. .

Excessive thirst and dry mucous membranes.

Answer and Explanation

The Correct Answer is C

A. Incorrect. Muscle weakness and fatigue are manifestations of hyperkalemia, but they are not the most critical indicators of severe hyperkalemia.

B. Incorrect. Tingling sensations in the extremities are not the most critical indicator of severe hyperkalemia.

C. Correct. The most critical manifestation of severe hyperkalemia is an irregular heart rhythm (dysrhythmiA. , which can be life-threatening.

D. Incorrect. Excessive thirst and dry mucous membranes are not specific to hyperkalemia and are not the most critical indicators of severe hyperkalemia.

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Correct Answer is A

Explanation

A. Correct. Encouraging the client to perform active range-of-motion exercises can help prevent complications of immobility, such as muscle wasting and joint contractures.

B. Incorrect. Elevating the head of the bed primarily benefits respiratory function and does not directly address the complications of immobility.

C. Incorrect. Limiting fluid intake would not prevent complications of immobility and may lead to dehydration.

D. Incorrect. Administering pain medication before passive range-of-motion exercises is not a standard practice and does not directly prevent complications of immobility.

A. Decreased blood volume and hypovolemia. B. Increased vascular permeability and leakage of fluid into tissues. C. Impaired filtration and reduced excretion of fluid by the kidneys. D. Excessive fluid intake and fluid overload.

Correct Answer is C

Explanation

A. Incorrect. Decreased blood volume and hypovolemia may contribute to prerenal acute renal failure, but they are not the primary pathophysiological processes that lead to edema in acute renal failure.

B. Incorrect. Increased vascular permeability and leakage of fluid into tissues are not the primary mechanisms of edema in acute renal failure.

C. Correct. In acute renal failure, the impaired filtration and reduced excretion of fluid by the kidneys lead to fluid retention and edema in various parts of the body.

D. Incorrect. Excessive fluid intake and fluid overload may contribute to fluid retention and edema in prerenal acute renal failure, but they are not the primary pathophysiological process in acute renal failure.

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A client with acute renal failure is at risk of developing hyperkalemia. What clinical manifestation is the most critical indicator of severe hyperkalemia in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with acute renal failure who is on bed rest. What intervention should the nurse implement to prevent complications of immobility?

Correct Answer is A

Explanation

A nurse is caring for a client with acute renal failure who develops edema. What is the primary pathophysiological process that leads to edema in this client?

Correct Answer is C

Explanation

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