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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Hypotension and tachycardia are more commonly associated with fluid depletion, not fluid overload.
B. Incorrect. Dry mucous membranes and decreased skin turgor are signs of dehydration, which is not indicative of fluid overload.
C. Correct. Fluid overload in acute renal failure can lead to pulmonary congestion and edema in the extremities. Crackles in the lungs (rales) are auscultated when there is fluid accumulation in the lung tissue, and edema in the extremities is visible swelling caused by excessive fluid retention.
D. Incorrect. Hypoactive bowel sounds and constipation are not directly related to fluid overload in acute renal failure.
Correct Answer is D
Explanation
:
A. Incorrect. Cheese and yogurt are high in phosphate and should be avoided in a low-phosphate diet.
B. Incorrect. Beans and lentils are also high in phosphate and are not suitable for a low-phosphate diet.
C. Incorrect. Eggs and poultry are significant sources of phosphate and are not recommended in a low-phosphate diet.
D. Correct. Fresh fruits and vegetables are generally low in phosphate and are suitable for a low-phosphate diet. These foods can help meet the client's nutritional needs while adhering to the dietary restriction.
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