A nurse is collecting data from a client who is in renal failure. The nurse should identify which of the following findings is a manifestation of hyperkalemia.

A. "I will take two 325 milligram aspirin tablets at the same time.": While aspirin is often recommended for heart attack prevention, taking two 325 mg tablets at the same time is not the standard recommendation for managing stable angina. The client should focus on using nitroglycerin as prescribed and seeking immediate medical attention if symptoms persist.

B. "I will stop what I am doing and lie down.": When chest pain occurs, the client should stop all activity and rest, preferably lying down. Resting can help reduce the heart's workload and alleviate the pain associated with stable angina.

C. "I will call the provider after taking one dose of nitroglycerin.": The correct action is to take one dose of nitroglycerin and wait five minutes. If the pain is not relieved, the client should take another dose and wait another five minutes. If the pain persists after three doses, the client should seek emergency medical help immediately rather than waiting to call the provider.

D. "I will hold my breath and bear down.": Holding the breath and bearing down (the Valsalva maneuver) is not recommended for relieving chest pain. This action can actually decrease venous return to the heart and increase strain on the heart, potentially worsening the situation.

A.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.

B.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.

C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.

D.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.