A nurse is caring for a patient who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?
Hyperactive bowel sounds
Decreased deep tendon reflexes
Cerebral edema
Weakening
The Correct Answer is B
Choice A reason: Hyperactive bowel sounds are not typically associated with hyperkalemia, which is a high level of potassium in the blood.
Choice B reason: Decreased deep tendon reflexes can be a sign of hyperkalemia, as high potassium levels can affect neuromuscular function.
Choice C reason: Cerebral edema is not a direct manifestation of hyperkalemia; it is more commonly associated with other conditions such as traumatic brain injury or stroke.
Choice D reason: Weakening, or muscle weakness, can be a symptom of hyperkalemia, but it is less specific than decreased deep tendon reflexes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While voluntary agreement is essential, understanding the procedure is the core of informed consent.
Choice B reason: Clarity is important, but it is not the sole requirement; the patient's understanding is crucial.
Choice C reason: Documentation is part of the process, but it does not replace the need for the patient's understanding.
Choice D reason: For informed consent to be valid, the patient must understand the nature and risks of the surgical procedure, which is the most critical aspect.
Correct Answer is B
Explanation
The correct answer is choice B. Raise the head of the bed.
Choice A rationale:
Increasing the patient’s oral fluid intake is important for hydration and thinning secretions, but it is not the immediate priority when oxygen saturation is critically low.
Choice B rationale:
Raising the head of the bed helps improve lung expansion and facilitates easier breathing, which can quickly improve oxygen saturation levels. This is a critical first step in managing low oxygen saturation.
Choice C rationale:
Initiating humidified oxygen therapy is essential for improving oxygenation, but it should follow the immediate action of raising the head of the bed to optimize breathing.
Choice D rationale:
Encouraging the patient to cough and deep breathe is beneficial for clearing secretions and improving lung function, but it is not the first action to take when oxygen saturation is critically low.
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